Effective Date: Immediately
Applies To: Utilization Management, Prior Authorization, and All Parties Capable of Remembering Things
1. Purpose
The Requester Integrity Standard (RIS-01) establishes uniform requirements for obtaining documentation during the prior authorization process. Its primary objective is to ensure that coverage determinations are made using information submitted specifically for review, rather than information already known, stored, or paid for by the organization.
This approach preserves objectivity, procedural consistency, and strategic amnesia across departments.
2. Scope of Review
Authorization reviewers shall evaluate requests using only the documentation provided within the current submission. Reviewers must not reference historical claims data, payment records, or previously approved services, even when such information directly answers the question being asked.
This separation ensures that decisions are based on fresh evidence, unencumbered by inconvenient confirmation.
3. Insulin and Monitoring Verification Protocol
When insulin therapy is requested, reviewers may require documentation demonstrating medical necessity in the presence of glucose monitoring equipment. Acceptable documentation includes clinical notes, letters of medical necessity, or any narrative capable of restating the obvious.
The existence of prior claims for glucose monitors, sensors, test strips, insulin, or related supplies shall not be considered sufficient evidence, as these data reside outside the authorization reviewer’s authorized awareness.
4. Conservative Therapy Attestation Requirements
For advanced imaging requests, providers must submit proof that conservative therapy has been completed, typically defined as six weeks of physical therapy. Documentation must independently establish duration, frequency, and patient participation.
Paid claims for physical therapy services, even when occurring consecutively over the required timeframe, shall not be referenced. Reviewers must treat the completion of therapy as a theoretical event until proven again.
5. Departmental Independence Safeguards
To maintain neutrality, utilization management staff shall not have access to claims processing systems. Likewise, claims staff shall not participate in authorization decisions.
This firewall protects the organization from accidental efficiency, unintended approvals, or the appearance of institutional memory.
6. Provider Documentation Responsibilities
Providers are responsible for reassembling information already possessed by the insurer and submitting it in approved formats. Submissions may be requested multiple times to ensure completeness, compatibility, and emotional alignment with internal workflows.
Failure to submit documentation previously paid for by the organization may result in delays, denials, or requests for additional documentation.
7. Determination Outcomes
Upon review, requests may be approved, denied, or returned for clarification. Outcomes shall not be influenced by internal billing data, prior approvals, or the insurer’s financial participation in the care being evaluated.
All determinations shall reflect a commitment to accuracy achieved through deliberate non-recognition.
8. Policy Rationale
By requiring information to be re-submitted without reference to existing records, RIS-01 ensures that each authorization is treated as a unique and memory-independent event. This standard reinforces consistency, protects process integrity, and upholds the foundational principle that knowing something once does not obligate the organization to remember it.
This policy replaces all prior guidance that implied awareness, continuity, or institutional recall.
