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Operationalizing UM Organization Determination: Member Discussion
Event Date: 11/18/2025
Event Overview
11/18/2025
12:30 PM – 1:30 PM CT (60 minutes)
Zoom Meeting
We’ve been hearing from members with questions about how to operationalize CMS’s “clarified” definition of organization determination under the 2026 final rule. Join us for a collaborative discussion to explore how plans are approaching this change while balancing compliance, member experience, and care delivery.
Discussion Points:
This interactive session is designed for members to share insights, compare approaches, and discuss challenges as we navigate these regulatory updates together. Everyone will have the opportunity to contribute and learn from their peers.
- How are plans approaching CMS’s “clarification” of the definition of organization determination in the 2026 final rule?
- Strategies to minimize member abrasion and unnecessary worry while ensuring medically necessary services are delivered
- Concerns about members receiving denial letters for inpatient level-of-care denials and the potential impact on appeals
Attendees
Below is a list of all delegates registered to date for this event
- Kimberly Bentz
- ALLIANCE MEMBER
- Director of Program Optimization at Health Alliance Plan (HAP)
- Traci Biondi
- ALLIANCE MEMBER
- Chief Medical Officer at Prominence Health Plan
- Charles Bloom
- ALLIANCE MEMBER
- Senior Vice President and Chief Medical Officer at Health Alliance Plan (HAP)
- Frank Borschke
- ALLIANCE MEMBER
- Medical Director at Health Alliance Plan (HAP)
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- Jamie Carlton
- ALLIANCE MEMBER
- Director of Utilization/Case Managment at Ochsner Health Plan
- Christian Corzine
- ALLIANCE MEMBER
- Vice President, Clinical Services & Operations at Medical Mutual
- Stephanie DeFalco
- ALLIANCE MEMBER
- Director of Prior Authorization at Medical Mutual
- Sarah Dencker
- ALLIANCE MEMBER
- Vice President, Care Services at Network Health
- Molly Eickholt
- ALLIANCE MEMBER
- Manager, HFHP Integrity at Health First Health Plans
- Ronald Encinares
- ALLIANCE MEMBER
- Lead, Project Coordinator at Health Alliance Plan (HAP)
- Lindsey Glass
- ALLIANCE MEMBER
- Director, Utilization Management at MediGold
- Kaitlyn Hammond
- ALLIANCE MEMBER
- Director of Government Programs at Cox HealthPlans
- Joan Healey
- ALLIANCE MEMBER
- Utilization Management Medicare Team Lead at Health Partners Plans / Jefferson Health Plans (HPP/JHP)
- Steve Hearon
- ALLIANCE MEMBER
- Medical Department Manager at Cox HealthPlans
- Megan Holly
- ALLIANCE MEMBER
- Government Programs Coordinator at Cox HealthPlans
- Melissa Janes
- ALLIANCE MEMBER
- Director Physician and Clinical Services at MediGold
- Cynthia Kernaghan
- ALLIANCE MEMBER
- UM Manager at Health Partners Plans / Jefferson Health Plans (HPP/JHP)
- Heather Krzyske
- ALLIANCE MEMBER
- Appeals and Grievances at Health Alliance Plan (HAP)
- Jared Lovan
- ALLIANCE MEMBER
- Medical Department Coordinator at Cox HealthPlans
- Daniel O'Connell
- ALLIANCE MEMBER
- Vice President of Health Services at Cox HealthPlans
- Preston Renshaw
- ALLIANCE MEMBER
- Chief Medical Officer at Avera Health Plans
- Jennifer Sheridan
- ALLIANCE MEMBER
- Manager Compliance & Training at Health Alliance Plan (HAP)
- Sandy Spitale
- ALLIANCE MEMBER
- Chief Clinical Officer at Ochsner Health Plan
- Lynn St. Hilaire
- ALLIANCE MEMBER
- Vice President of Clinical Services at MetroPlusHealth
- Patricia Suffern
- ALLIANCE MEMBER
- Chief Compliance Officer at MediGold
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- Yuri Sung
- ALLIANCE MEMBER
- Senior Specialist, Program & Strategy at Health Plan Alliance