In bad faith insurance litigation, the UR file is the central document. Plaintiff's counsel will subpoena the complete utilization review record — every reviewer note, every criteria citation, every peer-to-peer documentation entry, every communication log. What that record shows determines whether the denial is defensible or whether it becomes the plaintiff's best evidence.
What gets subpoenaed
The reviewer's notes and determination letters. The criteria screens applied — the specific InterQual or MCG criteria version, the clinical indicators checked, and the documented clinical evidence against each indicator. Peer-to-peer review documentation: when it was offered, when it occurred, what was discussed, and how it affected the determination. Reviewer credentials and specialty qualifications. Timeline documentation: how long the review took, how many records were reviewed, and whether the review timeline met regulatory requirements.
The documentation gaps that create exposure
Template language that does not address the specific clinical presentation. Peer-to-peer reviews that were offered but not documented. Criteria screens that show the reviewer checked indicators but did not document the clinical evidence considered for each. Reviewer notes that are sparse relative to the complexity of the case. These are the gaps that plaintiff attorneys identify and present to juries as evidence that the review was not conducted in good faith.
What in-house counsel should review now
Before bad faith litigation develops, in-house counsel and carrier legal teams should assess whether their UR documentation will survive plaintiff scrutiny. A UR Process Audit by a physician who has both conducted UR reviews and understands what plaintiff attorneys look for provides the pre-litigation assessment that allows remediation while remediation is still possible.