The UR process is governed by which type of written documents?

• A. Oral guidelines
• B. Administrative regulations
• C. Industry standards
• D. Written policies and procedures

Answer: (D)

Utilization Review decisions are guided by formal, documented policies and procedures. Having written guidelines ensures the process is consistent, auditable, and compliant, detailing how medical necessity is determined, who reviews cases, what criteria are used, timelines, and appeal rights. Oral guidelines lack enforceability and traceability, external administrative regulations describe rules from outside the plan rather than the internal process, and industry standards are general expectations that don’t by themselves govern the plan’s day-to-day operations. Written policies and procedures provide the binding framework that directs the UR workflow.