This process must include verification of the provider's credentials. Plans may not use a high risk patient or a provider's location in an area serving residents with poor health status as a basis for exclusion. Drug Utilization Program. The plan covers prescription medications, it must have a plan to encourage appropriate drug use and monitor and reduce illness arising from improper use. Standards for Utilization Review Activities.
Utilization review refers to the plan's review of requests for care.
It is defined as evaluation of clinical necessity and efficacy. Written clinical review criteria are required. Utilization review must be supervised by a licensed physician. Its activities must be executed by appropriately qualified staff. There can be no incentives to render adverse determinations.