Clinical Scope
Review types, lines of business, specialties, populations, and escalation pathways.
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Contracting & RFPFlexible physician-review support built around your UM workflow.
Start a conversation about ongoing review coverage, overflow capacity, appeals, targeted initiatives or a customized physician-advisory engagement.
PROCUREMENT & RFP READINESS
Define the engagement before the first case is reviewed.
A strong physician-review proposal should make the clinical scope, operating model, information-governance requirements, and commercial structure clear enough for medical, operational, compliance, and procurement teams to evaluate together.
RFP discussions can be tailored to the contracting organization.
Specific credentials, service levels, security representations, staffing assumptions, and contractual commitments should be confirmed for the applicable engagement.
Physician Qualifications
Required licensure, credentials, experience, specialty needs, and role expectations.
Workflow & Turnaround
Case intake, coverage windows, turnaround expectations, P2P workflows, and escalation.
Quality & Reporting
Documentation expectations, quality oversight, reporting, and performance-review requirements.
Privacy & Security
BAA requirements, approved information exchange, access controls, and engagement-specific safeguards.
Commercial Structure
Volume assumptions, pricing model, reserved capacity, implementation needs, and contract terms.
FROM DISCOVERY TO CONTRACTED WORKFLOW
A straightforward path to a defined physician-review engagement.
1DiscoveryReview mix, volume, coverage window, specialties, and operational need.
2Service DesignWorkflow, turnaround, escalation, reporting, and secure information exchange.
3Proposal & ContractingScope, pricing, credentials, service expectations, privacy terms, and responsibilities.
4Implementation PlanningAuthorized workflow, contacts, systems, quality expectations, and launch readiness.
Flexible physician-review engagement models
Physician-review support can be configured around the organization’s clinical scope, workflow, volume, turnaround requirements, and coverage needs. The operating model should support the UM program without compromising independent physician judgment.
Ongoing
Ongoing Review Coverage
Regular physician-review capacity integrated into an established utilization-management workflow.
Defined review categories · Coverage windows · Escalation pathways · Ongoing operational supportFlexible
Overflow & Backlog Support
Additional physician capacity for temporary volume pressure, accumulated queues, vacations, vacancies, or concentrated review demand.
Variable volume · Temporary coverage · Backlog reduction · Capacity supportEscalation
Complex-Case Escalation
Focused physician review for ambiguous, disputed, or high-risk cases requiring additional clinical judgment.
Patient status · Appeals · P2P · Complex medical necessity · Specialty questionsTargeted
Targeted Programs
Defined review initiatives built around a population, service line, review category, or operational need.
Focused initiatives · Defined populations · Specialized workflows · Program supportEngagement factors
Review typeClinical complexityCase volumeTurnaround timeSpecialty requirementsP2P requirementsCoverage hoursReporting & integration
Clinical independence: Fees are based on professional services and the agreed engagement structure—not on whether a case is approved or denied and not on the financial outcome of a determination.
Commercial terms can be tailored to the engagement
Depending on scope and operational requirements, commercial arrangements may include per-case professional fees, volume-based arrangements, reserved physician capacity, or a customized program structure. Specific pricing and service levels are defined during proposal and contracting discussions.
What UMPA can coordinate during contracting
Contracting requirements vary by organization. During due diligence and implementation planning, UMPA can coordinate applicable organizational and physician information needed to evaluate and operationalize the engagement.
- Physician qualifications, licensure, credentials, and relevant experience as applicable to the engagement
- Professional liability and other requested vendor documentation, as applicable and available
- W-9 and organizational vendor information
- BAA and privacy requirements when applicable to the authorized workflow
- Defined review scope, coverage windows, turnaround expectations, and escalation pathways
- Secure information-exchange and system-access requirements
- Documentation, reporting, quality, and performance expectations
- Implementation contacts, workflow testing, and launch-readiness planning
Specialized expertise
Explore Two-Midnight ReviewMedicare & patient-status review
Complex Medicare reviews may require additional physician analysis of CMS coverage requirements, the Two-Midnight framework, patient status, clinical trajectory, applicable coverage criteria, and the supporting medical record.
What helps us scope an engagement
These details help define physician capacity, workflow, turnaround expectations, reporting, and implementation requirements.
- Organization and line of business
- Review types and clinical specialties
- Estimated review volume and expected coverage window
- Turnaround-time requirements
- Criteria, medical policies and regulatory framework
- Required documentation and escalation workflow
- Technology and secure information-exchange requirements
- Quality reporting and performance expectations
Start a contracting discussion
Share your review mix, approximate volume, turnaround requirements, coverage needs, or a non-PHI RFP summary. Initial business inquiries may be submitted through our consultation form or sent to contact@umphysicianadvisors.com. Please do not include patient or member information in an initial inquiry.
Next step: after an introductory discussion, scope, service levels, security requirements, commercial terms, credentials, responsibilities, and implementation requirements can be defined for the specific engagement.
RELATED CLINICAL RESOURCES
Explore the clinical frameworks behind our reviews.
Reference the coverage, patient-status, evidence, and medical-necessity frameworks that inform physician review when applicable to the engagement.
PRIVACY & INFORMATION GOVERNANCE
Clinical-review contracting should define how protected information moves through the engagement.
Privacy and information-governance requirements are engagement-specific and should be aligned before patient-level review begins.
Business Associate Agreement
Determine whether the relationship requires a BAA and define permitted and required uses and disclosures of PHI.
Secure Information Exchange
Define approved systems and channels for case intake, clinical documentation, determinations, and related communications.
Access & Minimum Necessary
Align information access with the authorized review purpose and applicable privacy requirements.
Incident & Escalation Responsibilities
Establish applicable notification, escalation, and response responsibilities through governing agreements and procedures.
Retention & Disposition
Clarify engagement-specific record retention, return, disposition, and documentation expectations where applicable.
Subcontractor / Vendor Requirements
Address downstream obligations when another party creates, receives, maintains, or transmits PHI as part of the authorized workflow.
Ready to define a physician-review engagement?
Tell us your review mix, approximate volume, turnaround requirements, coverage needs, and operational priorities.
Contractable Physician Review Capabilities
Core UM Reviews
Prior authorization, patient status, concurrent/continued stay, retrospective medical necessity, peer-to-peer, post-acute, and related physician review.
Appeals & PDR
Independent physician review supporting appeals and Provider Dispute Resolution matters involving medical necessity, authorization, status, or other clinical determinations.
Clinical Grievances & Validation
Physician review of clinically substantive grievances and clinical validation of diagnoses or conditions supported by the record.
Education & Calibration
Case-based physician reviewer education and calibration focused on consistency, documentation, clinical rationale, CMS frameworks, and defensible determinations.