4-5 Vt. Code R. 3:10.300 - Additional requirements if utilization management mechanisms are used under the Department of Financial Regulation regulations

“Additional requirements if utilization management mechanisms are used under the Department of Financial Regulation regulations”

 (3.1) Each managed care organization is responsible for monitoring all utilization management activities. A managed care organization that conducts utilization management must implement a written utilization management program that describes all utilization management activities for services provided to members. Utilization review guidelines must be informed by generally accepted medical and scientific evidence and clinical practice parameters. The guidelines must be made available to all providers under contract with the managed care organization. 

(3.2) Each managed care organization must maintain written procedures for making utilization review decisions and for notifying members and providers with information about its utilization reviews.