Licensed vs internal UM criteria: what must payer software do differently for each?
Utilization management reviewers apply medical necessity criteria from one of two places: a licensed criteria set maintained by a content vendor, or criteria the health plan writes and maintains itself. The software around them differs in how content is integrated, versioned, published, cited in decisions and, one day, replaced.
How do licensed and internal UM criteria differ in the software?
Quick answer
Licensed vs internal UM criteria changes the software more than the review screen: licensed sets arrive through a vendor integration with display and storage limits, while internal criteria need authoring, versioning, evidence and, for Medicare Advantage, public posting. Agnotic Technologies builds UM workbenches that store the criteria version and evidence with every decision.
| Criterion | Licensed criteria | Internal criteria |
|---|---|---|
| Who owns the content | The content vendor; the plan licenses its use | The plan's clinical policy team |
| Update cycle | Vendor releases; the plan decides when to adopt each one | The plan's own review cycle, with MA UM policies reviewed at least annually by the UM committee |
| Integration | Vendor API or embedded viewer inside the workbench | Plan criteria library or rules engine inside the workbench |
| Storage and display | Licence terms may limit what you store, show or send to providers | No licence limits; you decide what to store and show |
| Versioning | Record the vendor release and edition used for each decision | Version each criterion with effective and retired dates |
| Public posting for MA | If used as internal coverage criteria, confirm the licence allows what 422.101(b)(6) requires to be public | Publish the criteria in use, an evidence summary, the sources and the rationale |
| Evidence | Vendor supplies the evidence references | The plan maintains the evidence summary and sources |
| Decision record | Criteria set, release and section applied, without copying licensed text beyond the licence | Criterion ID, version, evidence link, reviewer and outcome |
| Committee approval | The UM committee approves the policies that use the set | The UM committee reviews and approves the criteria and procedures |
| Exit path | Keep decisions explainable after the licence ends: version references and permitted extracts | The content stays with the plan; export the library and its history |
What they are
What is Licensed criteria
A licensed criteria set is medical necessity content written and updated by a content vendor and licensed to the plan. Reviewers use it through the vendor's integration or viewer inside the UM workbench. The plan controls when it adopts each release, but not the content.
What is Internal criteria
Internal criteria are written and maintained by the plan's own clinical policy team, approved through its committees, and stored in a criteria library or rules engine the plan controls. The plan owns the content, the evidence summary and every change.
Key differences
What does Medicare Advantage require of internal coverage criteria?
Under 42 CFR 422.101(b)(6), MA organizations may create publicly accessible internal coverage criteria based on current evidence when Medicare coverage criteria are not fully established. They must publish the criteria in use, a summary of the evidence considered, a list of its sources and the rationale for adopting them. The software needs a publication path from the criteria library to a public page, versioned so the published text matches what reviewers applied on any date.
What does the UM committee have to approve?
42 CFR 422.137 requires an MA organization that uses utilization management to have a UM committee led by a medical director, and bars UM policies and procedures that the committee has not reviewed and approved. The committee must review all UM policies at least annually and document the reasons for its decisions. Store committee approvals against criteria versions, so you can show which approval covered which decision.
How does a licensed criteria set plug into a UM workbench?
Usually through the vendor's API or an embedded viewer that opens at the right guideline for the request. Plan for single sign-on, context passing (member, service, diagnosis), capturing which criteria points the reviewer marked as met, and returning a result to the case. Read the licence before designing storage: some terms limit how much content you keep in your own database or show to providers.
Why store the criteria version with every decision?
Appeals and audits ask what the reviewer applied on the day of the decision, not what the criteria say now. Store the criteria source, version or release, the sections applied, the evidence the reviewer used, the reviewer and the outcome. Without that, a criteria update can make a sound past decision impossible to explain.
How do documentation requirements reach providers?
Through the provider's EHR, if you implement HL7 Da Vinci Documentation Templates and Rules. DTR uses FHIR Questionnaires with embedded CQL logic and value sets to pull existing information from the EHR, prompt for what is missing and decide which questions need answers. Each questionnaire version must track the criteria version it reflects. Our AI prior authorization page covers the submission side.
Can a plan run both?
Most do: a licensed set for broad coverage and internal criteria where the set does not fit. The workbench then needs one decision record format for both sources, clear routing rules for which source applies to which request, and reporting that shows where internal criteria are in use.
When to use each
When to use Licensed criteria set
- You need broad clinical coverage without a large clinical policy team.
- Providers and reviewers already know the set from other plans.
- You want vendor-maintained evidence references and release notes.
- Licence terms allow the display and storage your workflows need.
When to use Internal (plan-developed) criteria
- Licensed content does not cover a service, population or benefit you manage.
- You need criteria tailored to a specific program or local practice.
- You must publish criteria in full, with evidence and rationale.
- You want no licence limits on display, storage or provider access.
Where does criteria handling fail an appeal or an audit?
1. Criteria version not stored with the decision. Fix: write source, version and sections to the decision record at the moment of decision.
2. Internal criteria in use but not published. Fix: publish from the same library reviewers use, and block activation of unpublished criteria for MA requests.
3. A denial reason that does not say which criterion was not met. Fix: generate the reason from the criteria points recorded, then let the reviewer edit.
4. Criteria applied after their retired date. Fix: effective and retired dates enforced by the workbench, not by memory.
5. Licensed text copied into letters or portals beyond the licence. Fix: reference sections by ID and keep extracts within the licence terms.
6. Reviewer overrides without a recorded rationale. Fix: require a reason and evidence for any decision that departs from the criteria.
7. Criteria changed without a committee approval on record. Fix: link every activated version to its approval.
8. Documentation questionnaires out of step with the criteria. Fix: version questionnaires with the criteria they reflect and retire both together.