MRE BUYER GUIDE · A BHM HEALTHCARE SOLUTIONS RESOURCE
A utilization management review partner should solve a clearly defined operational problem. Before comparing vendor claims, establish which work needs support, where delays or quality issues arise, and what your team will continue to own.
This guide helps health plan leaders compare internal, outsourced, and hybrid review models; test vendor capacity; and define measurable expectations for quality, timeliness, and implementation.
Take the UM partner checklist with you
Use this three-page checklist to define requirements, evaluate evidence, and compare up to three partners. Fill it in digitally or print it for vendor conversations.
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The practical takeaway
Define the operational problem before comparing vendors. Make workflow ownership explicit, test capacity against your case mix, and evaluate quality, timeliness, implementation effort, and cost together.
What are utilization management reviews?
Utilization management reviews assess healthcare services against the applicable clinical, coverage, and process requirements. Reviews may occur before services are delivered, during an episode of care, or afterward. The purpose, reviewer qualifications, workflow, and decision authority depend on the review type and program.
Outsourcing a review task does not automatically transfer every responsibility associated with it. Define the work to be performed and have your clinical, operational, and compliance teams confirm the allocation of responsibilities.
1. Define the problem before writing the requirements
Separate the symptoms from the work you need a partner to perform. A growing queue, for example, could reflect missing records, inefficient handoffs, specialty shortages, fluctuating volume, or several factors at once.
| Observed issue | Question to investigate | Requirement to test |
|---|---|---|
| Backlog growth | Where does work wait, and why? | Capacity aligned to the actual bottleneck. |
| Inconsistent reports | Which elements require clarification or rework? | Report standards and quality checks. |
| Unpredictable completion | Are timing definitions and urgency rules clear? | Segmented measures and escalation ownership. |
| Specialty gaps | Which cases cannot be assigned reliably? | Relevant reviewer availability and backup coverage. |
2. Compare internal, outsourced, and hybrid models
| Model | Potential fit | Questions to resolve |
|---|---|---|
| Internal | Your organization has the expertise and capacity to manage the work directly. | How will staffing, coverage, quality oversight, and surges be supported? |
| Outsourced | A defined workflow or case category is assigned to a partner. | Which responsibilities transfer, and how will your team oversee performance? |
| Hybrid | Internal teams retain selected work while a partner handles specialties, overflow, or defined review stages. | How will routing, handoffs, escalation, and duplicate work be controlled? |
The right model depends on your case mix, staffing, systems, and operating requirements. Compare models against the same practical scenarios rather than assuming one structure will always cost less or perform better.
3. Make workflow ownership explicit
Walk through a representative case from intake to closure. Name one accountable owner for each task and identify the system in which the work will be recorded.
| Workflow stage | Ownership questions |
|---|---|
| Intake and completeness | Who confirms that the required information is available? Who requests missing records? |
| Clinical assignment | Who matches the reviewer, checks conflicts, and monitors assignment delays? |
| Review and clarification | Who answers questions about scope, criteria, or the clinical record? |
| Decision and communication | Who has decision authority, and who issues notices or communicates results? |
| Delivery and reporting | How does the report reach the correct system? Who checks exceptions? |
| Correction and escalation | Who responds when a report needs clarification or a case is at risk? |
4. Test actual capacity
Ask how capacity is planned for the specialties and review types you need. A network size or general coverage claim does not establish capacity during your busiest periods.
- Provide a representative distribution of cases by specialty, urgency, complexity, and time of arrival.
- Ask about current availability, assignment acceptance, backup coverage, and surge limits.
- Define the notice required for a volume increase and the point at which the vendor will escalate a capacity constraint.
- Use de-identified scenarios to test operational responses without exposing patient information during initial evaluation.
Illustrative example: A fictional plan has manageable average volume but receives a recurring concentration of specialty cases on Mondays. A vendor offering sufficient weekly capacity may still miss the plan’s needs if the required reviewers are unavailable during that window. Evaluate when capacity is available as well as how much exists.
5. Use a balanced performance scorecard
Review performance across clinical quality, operational reliability, and timing. Define each measure before setting a target. Separate standard and expedited work, and identify exclusions or pauses explicitly.
| Area | Measure to define | Question for the vendor |
|---|---|---|
| Quality | Completeness, clarification, and correction measures | What is checked before delivery, and how is rework categorized? |
| Timeliness | On-time completion and elapsed time by case segment | When does the clock start, pause, and stop? |
| Capacity | Assignment delays, acceptance, and coverage exceptions | How are gaps identified and escalated? |
| Reliability | Handoff failures and unresolved exceptions | Who owns follow-up, and how quickly are issues acknowledged? |
| Improvement | Recurring issue analysis and corrective action | How are changes documented and checked for effectiveness? |
6. Evaluate implementation and the true operating cost
A per-case rate is only part of the comparison. Identify implementation effort, integration needs, additional fees, internal oversight, and time spent obtaining missing information or correcting reports.
- Request an itemized scope, including what is excluded and what triggers additional charges.
- Document system access, security review, training, reporting, and interface dependencies.
- Agree on acceptance criteria and the owner of each implementation milestone.
- Plan a controlled start with defined case types, escalation contacts, and a review of early results.
- Clarify termination, record access, and transition arrangements before signing.
Build your requirements worksheet
For each requirement, record its priority, the evidence requested, the evidence received, the remaining gap, the owner, and the decision date. Have the same internal reviewers assess every vendor.
| Requirement | Priority | Evidence and gap to record |
|---|---|---|
| Clinical expertise and case fit | Required / preferred | Qualification standards, matching examples, and unresolved coverage gaps. |
| Workflow ownership | Required / preferred | Agreed responsibility map and open handoffs. |
| Quality and reporting | Required / preferred | Sample outputs, definitions, and reporting examples. |
| Capacity and turnaround | Required / preferred | Segmented commitments and exception procedures. |
| Implementation and cost | Required / preferred | Milestones, dependencies, total fees, and assumptions. |
Frequently asked questions
What is the difference between utilization management and utilization review?
Organizations use these terms differently. Utilization management often refers to a broader program, while utilization review describes evaluation of particular services or episodes. Ask vendors to define exactly which activities are included in their proposal.
Can a partner support our internal team without taking over the entire process?
A hybrid arrangement can assign defined case types, specialties, or overflow work to a partner. Its effectiveness depends on clear routing rules, ownership, system handoffs, and performance oversight.
How should we compare vendor turnaround claims?
Use matching clock definitions, urgency categories, case types, reporting periods, and exclusions. Consider late cases and exceptions alongside averages, and evaluate report quality at the same time.
Discuss your review model with BHM
MRE is a BHM Healthcare Solutions brand. Bring your case mix, volume pattern, review stages, and current operational challenges to a conversation about medical review support.
Use the IRO evaluation guide · Explore BHM Healthcare Solutions
Please do not send patient information or medical records through a general inquiry. Confirm program-specific clinical, legal, compliance, and security requirements with your internal specialists.
Sources and further reading
NCQA: Utilization Management Accreditation describes a framework involving relevant clinical information, qualified health professionals, and evidence-based review processes. Use the issuing organization’s current program information when evaluating accreditation claims; this guide is not a substitute for the applicable standards.
Content updated October 28, 2026. Confirm program-specific requirements with your clinical and compliance teams.