A UM and case management program build is the work of writing a utilization management or case management program from the ground up: program descriptions, committee charter, policies, decision workflows, letter templates and training. It is for health plans, delegated entities and provider organizations building UM or case management. Integral Healthcare Solutions (IHS) drafts the program, policies and clinical content for your clinicians to review and approve, mapped to the federal rules and contract terms your lines of business carry.

Last reviewed: October 2026.

What is a UM and case management program build?

It is a documented operating program, written against the text that governs each line of business you serve. The federal texts IHS works from, read in their current eCFR versions in October 2026:

• 42 CFR 422.137, the Medicare Advantage Utilization Management Committee: "An MA organization that uses utilization management (UM) policies and procedures, including prior authorization (PA), must establish a UM committee that is led by a plan's medical director" (42 CFR 422.137(a)).
• 42 CFR 422.566, organization determinations: "Each MA organization must have a procedure for making timely organization determinations (in accordance with the requirements of this subpart) regarding the benefits an enrollee is entitled to receive under an MA plan" (42 CFR 422.566(a)).
• 42 CFR 422.568, standard timeframes: "Beginning on or after January 1, 2026, for a service or item subject to the prior authorization rules in § 422.122, 7 calendar days after receiving the request for the standard organization determination" (42 CFR 422.568(b)(1)(ii)).
• 42 CFR 438.210, Medicaid managed care coverage and authorization: "For rating periods that start on or after January 1, 2026, within state established time frames that may not exceed 7 calendar days after receiving the request for service" (42 CFR 438.210(d)(1)(i)(B)).

The committee rule reaches every UM policy an MA plan uses: "An MA plan may not use any UM policies and procedures for basic or supplemental benefits on or after January 1, 2024 unless those policies and procedures have been reviewed and approved by the UM committee" (42 CFR 422.137(b)). The committee must also "At least annually, review the policies and procedures for all utilization management, including prior authorization, used by the MA plan" (42 CFR 422.137(d)(1)).

The review rule shapes who signs a denial: "If the MA organization expects to issue a partially or fully adverse medical necessity (or any substantively equivalent term used to describe the concept of medical necessity) decision based on the initial review of the request, the organization determination must be reviewed by a physician or other appropriate health care professional with expertise in the field of medicine or health care that is appropriate for the services at issue, including knowledge of Medicare coverage criteria, before the MA organization issues the organization determination decision" (42 CFR 422.566(d)).

State UR licensing law and state Medicaid contracts add their own terms. IHS scopes those per client from the contracts you provide.

Who needs it and what triggers it

Plans, delegated entities and provider organizations that start or rebuild UM or case management need the program written first. Common triggers:

• A Medicare Advantage organization that uses UM or prior authorization and has no UM committee, charter or minutes that meet 42 CFR 422.137 (eCFR).
• Decision timeframes that predate 2026. The 7-calendar-day standard for MA items subject to the 422.122 prior authorization rules applies on or after January 1, 2026 (42 CFR 422.568), and the Medicaid managed care limit applies to rating periods starting on or after January 1, 2026 (42 CFR 438.210).
• Adverse medical necessity decisions issued without a documented review by a physician or other appropriate health care professional, which 42 CFR 422.566(d) requires for MA plans before the decision issues (eCFR).

How IHS helps

IHS drafts the program, policies and clinical content for your clinicians to review and approve. The process:

1. Gap assessment of your current documents against the governing texts for each line of business, and against your state contracts and delegation agreements.
2. Questionnaires that collect your operating facts: lines of business, staffing, systems, current letters.
3. Document and evidence mapping: a crosswalk from each cited regulation and contract term to the policy, form, log or record that meets it.
4. Drafting the UM program description and case management program description; the UM committee charter, membership matrix and minutes templates; policies and procedures for intake, clinical review, peer and physician review, determinations and notices, timeframes and extensions, appeals hand-off, criteria selection and annual review, inter-rater reliability, delegation oversight, and case management assessment, care planning, transitions and closure; workflows and decision-timeline tables keyed to your lines of business; letter and form templates; and reviewer and case manager training material. Facts only you can supply are marked as open items.
5. Mock review of the drafted program against the same texts.
6. Readiness support: a work plan and training for reviewers and case managers.

What you supply

Your lines of business, state contracts and delegation agreements, staffing, system screenshots and current letters.

Who decides what

Your medical director and clinical leaders choose the clinical criteria, set clinical policy and approve every clinical document. For MA plans, your UM committee approves the UM policies, as 42 CFR 422.137 requires.

The limit

IHS makes no coverage or medical necessity decisions and gives no legal opinion. State and contract requirements are scoped per client.

What to have ready

Gather what exists; missing items become part of the build.

• A list of your lines of business (Medicare Advantage, Medicaid managed care, commercial or delegated), since each carries different timeframes (42 CFR 422.568; 42 CFR 438.210).
• For MA: your UM committee roster, showing the medical director who leads it and the composition 422.137(c) requires (42 CFR 422.137(a)).
• For MA: every UM and prior authorization policy in use, with the date the UM committee approved it (42 CFR 422.137(b)).
• For MA: the minutes of the committee's most recent annual review of all UM policies (42 CFR 422.137(d)(1)).
• Your current organization determination procedure (42 CFR 422.566(a)).
• A roster of the physicians and other health care professionals who review potential adverse medical necessity decisions, with their fields of expertise (42 CFR 422.566(d)).
• Your current standard decision timeframes and the list of MA items subject to the 422.122 prior authorization rules (42 CFR 422.568(b)(1)(ii)).
• For Medicaid managed care: the state-established timeframes in your contract and the start date of your rating period (42 CFR 438.210(d)(1)(i)(B)).
• Your current determination letters and notices, to be checked against the procedure they carry out (42 CFR 422.566).

Bring whatever you have to the introductory call; the gaps on this list are where the build starts.

How it compares

Building the program and having it accredited are separate pieces of work. Some organizations build to an accreditor's standards from the start; others build to their regulatory and contract terms first.

See also the Program Development practice line.

What it costs

URAC does not publish a fee schedule on the pages we reviewed; fees depend on scope. IHS scopes each engagement after a free introductory call.

What this is not

• This page is not legal advice. IHS identifies the regulations and contract terms your counsel should read; it does not give an opinion on them.
• IHS does not make coverage or medical necessity decisions, choose clinical criteria or sit on your UM committee.
• IHS does not file anything with CMS, a state agency or an accreditor, and does not guarantee an accreditor's decision. IHS drafts; your organization adopts the program and runs it.

Frequently asked questions

What does a Medicare Advantage UM committee have to look like?

42 CFR 422.137(a) states that an MA organization that uses UM policies and procedures, including prior authorization, must establish a UM committee that is led by a plan's medical director. Section 422.137(c) sets the composition: a majority of members who are practicing physicians, at least one independent practicing physician free of conflict, at least one practicing physician who is an expert in the care of elderly or disabled individuals, and members representing various clinical specialties. IHS drafts the charter, a membership matrix and minutes templates for your organization to adopt. Your leaders name the members within those rules.

Which UM policies does the committee have to approve, and how often?

Under 42 CFR 422.137(b), an MA plan may not use any UM policies and procedures for basic or supplemental benefits on or after January 1, 2024 unless the UM committee has reviewed and approved them. Under 422.137(d)(1), the committee must review the policies and procedures for all utilization management, including prior authorization, at least annually.

Who must review a request before we issue an adverse medical necessity decision?

For MA plans, 42 CFR 422.566(d) states that when the organization expects to issue a partially or fully adverse medical necessity decision, the determination must be reviewed by a physician or other appropriate health care professional with expertise appropriate for the services at issue, including knowledge of Medicare coverage criteria, before the decision issues. The peer and physician review procedure IHS drafts builds that step into the workflow.

What are the 2026 decision timeframes for standard prior authorization requests?

For MA, 42 CFR 422.568(b)(1)(ii) sets 7 calendar days after receiving the request, beginning on or after January 1, 2026, for a service or item subject to the prior authorization rules in 422.122; for other items, 422.568(b)(1)(i) keeps standard determinations at 14 calendar days. For Medicaid managed care, 42 CFR 438.210(d)(1)(i)(B) sets state-established timeframes that may not exceed 7 calendar days, for rating periods that start on or after January 1, 2026.

What written policies, workflows and letters does a new UM program need?

IHS drafts a UM program description, committee charter and policies for intake, clinical review, peer and physician review, determinations and notices, timeframes and extensions, appeals hand-off, criteria selection and annual review, inter-rater reliability and delegation oversight.

How do we build a case management program description, assessment and care plan workflow?

IHS drafts the case management program description and policies for assessment, care planning, transitions and closure, with workflows and training material for case managers. Your clinical leaders approve the clinical content before it is used.

How do we oversee a delegated UM or case management vendor?

IHS drafts a delegation oversight policy and maps it to your delegation agreements and contract terms.

Which clinical criteria can we use, and who approves them?

Your medical director and clinical leaders choose the clinical criteria and set clinical policy. IHS drafts the criteria selection and annual review procedure.

Should we build to URAC HUM or NCQA standards from the start?

That choice depends on your contracts, your customers and the program you run. IHS can map the build to either accreditor's standards once you have purchased them. Maureen Plumstead leads IHS's NCQA accreditation and recognition engagements.

What is the difference between building the program and getting it accredited?

The build writes the program your staff run. Accreditation reviews an existing program against an accreditor's standards and is decided by the accreditor. IHS covers accreditation on separate pages; this page covers the build.