The Basics

This standard establishes the circumstances under which you must expedite a review and the time frames and notification requirements for such a review.

You must provide an expedited review where the normal timeframe would jeopardize the life or health of the consumer or the consumer's ability to regain maximum function.

An expedited review must be completed as quickly as possible and in no case more than 72 hours from receipt of the initial information packet.  If you need to get more information, you may extend this deadline for 24 hours, but not any longer.  If you don't receive the information within that deadline, you must submit it for review in any event.

Once you've made a determination, you must immediately notify the referring entity.

Management Tips

Again, the most restrictive timeframe applies.  Make sure your policy and procedures are very clear on both that triggering mechanism for an expedited review and the time frames.  Many organizations struggle to articulate how to handle a need for more information in a way that is compliant with the standard, so take particular care as you write that language.

URAC Accreditation Tips

Four of the five elements of this standard are mandatory; the final one, involving notification, is worth four points.

For purposes of the desktop review, submit not only are policies and procedures regarding expedited reviews, but also any contractual and regulatory requirements under which you must operate.

The on-site reviewer will not only talk with the medical director about expedited reviews, but also will look for documentation that you comply with your expedited review policy and procedures, specifically in her review of your 30 case files.

The Basics

This standard establishes time frames for standard reviews where the timeframe is not established by regulation. First, you need to maintain a median duration of five business days.  Second, you must never exceed 20 business days.  Third, the clock starts ticking once your organization has received all of the information, including any additional information that has been submitted by the consumer and/or referring entity.

"Median" is the middle value in a range of numbers.  In other words, half of your cases need to be completed within five business days.

Management Tips

You are likely to find yourself in a matrix of time constraints, contractual, regulatory, URAC, and even in terms of your own policies and procedures.  The most stringent timeframe is the one that will apply.  

Your policy and procedure actually may control your timelines more rigorously than does this standard.  Notice that the first element provides for an average of five business days.  If your P&P reads that the review will be completed within five business days, it, and not the standard, must be followed.  Failure to implement your own policies, you will recall, is a violation of Core 3(a).  

URAC Accreditation Tips

Two elements of this standard are worth four points; the third is worth three points.

For the desktop review, submit your applicable policies and procedures, any contractual or regulatory time frames, and some evidence that you monitor your organization's compliance with the standard and the other applicable guidelines.

The on-site reviewer will interview the medical Director and examined the 30 selected case files for evidence of compliance with the time frames of this standard and/or any applicable regulations or contract provisions.

The Basics

This standard requires that you send a notice of your organization's determination in the Independent review case no more than two business days after rendering that determination.  The notice must be sent to the referring entity.

The standard goes on to require three elements to that notice:

• the issue considered by the reviewer;
• the qualifications of the reviewer; and
• an explanation for the determination, in particular, a clinical rationale if the case is clinical in nature.

By "referring entity", URAC means whoever sent the case to your organization for review, whether that be the health plan, enrollee, provider, or state regulator.

Management Tips

Let your contracts and applicable regulations be your guide as you design your policies and procedures around determination notification. In both contracts and regulation can dictate timing and recipient of the notice of determination.  However, if there is a conflict between regulation and this standard, the more rigorous will apply.  Therefore, if the state requirement is, for example, a three-day notice deadline, you still must meet the two-day deadline of this standard.

It's also important to note that this standard does not limit your ability to send the review determination to persons or parties other than the referring entity.  Contract or state law may limit you, but this standard does not.

It will be particularly important that you document when the notice of determination was actually sent.  Merely showing the date on the letterhead may not be enough, as it is not proof that the notice was sent the day it was composed.

URAC Accreditation Tips

The element requiring an explanation of the determination is mandatory; the other two elements are worth four points each.

For the desktop review, submit the applicable policy and procedure as well as templates of the notices of determination that you use.

During the on-site review, the reviewer will assess compliance with the standard through interviews of staff members and two reviewers.  In addition, she will assess compliance through her audit of case files, looking specifically for notices of determination in each file for which there is a determination.

The Basics

In the relatively rare circumstance where you need to use more than one reviewer on the case, under this standard, you must allow the reviewers to discuss the case with each other and accept the decision of the majority of the reviewers.  Dissenting reviewers should have an opportunity to document the reason for their dissent in the case file.

Management Tips

What happens when you have an even number of reviewers and you have a tie?  In such a case, you must seek the opinion of an additional reviewer in order to break the tie.

URAC Accreditation Tips

The two elements of this standard are worth three points each.

You need submit only the policy and procedure describing multiple-reviewer cases for the desktop review.

The on-site reviewer will interview and observe your staff members, and look for compliance with the standard in her review of the 30 case files.

The Basics

For all three of the different types of reviews described in the previous three standards, your organization must have mechanisms by which you can request and accept any additional information that the reviewer may need to make a determination.  If, upon such a request, the consumer or attending provider submits additional information, your organization must provide a copy of that information to the health plan.  The purpose of this requirement is to allow the health plan a chance to reverse its initial determination and save itself the cost and trouble of an independent review.  If the health plan does reverse its decision, the review process comes to an end.

Management Tips

Your policy and procedure addressing additional information must not only clearly describe, with time frames included, the process of requesting such information, but also the processes involved in handling that information, i.e., getting the information to the health plan and/or the reviewer.  Naturally, your case files will need to document all such steps, so make sure that if you audit case files, your audit includes an examination of documentation for seeking and handling additional information.

URAC Accreditation Tips

This standard is worth four points.

For the desktop review, all you need to submit is the policy and procedure that describes how your organization seeks and handles additional information.  However, if you have a template letter that you use to request such additional information, we recommend that you submit that, too.

The on-site reviewer will assess compliance with this standard through both her interviews with staff members involved in the process of seeking and handling additional information and her review of the randomly selected 30 case files.

The Basics

While the previous two standards addressed clinical reviews, this standard deals solely with administrative and legal case reviews.  For most organizations, this is fairly uncommon.  This standard requires that, in such cases, the organization and the reviewer consider all necessary information, including such factors as the health plan benefits as described in the contract and other materials, as well as any applicable law or regulation.

Management Tips

Your policy and procedure describing administrative and legal reviews should make it clear how your organization determines that this is a non-clinical case appropriate for such a review, which reviewer(s) handle such cases, and how materials needed for the review are forwarded to that reviewer.

URAC Accreditation Tips

The standard is worth four points.

The only documentation needed for the desktop review is the policy and procedure for administrative and legal case review.

During the on-site review, the reviewer will not only interview the administrative/legal reviewer, but also try to select one or more administrative/legal cases among the 30 case files examined.

The Basics

Whereas the previous standard dealt with cases involving issues of medical necessity, this standard addresses cases involving issues of experimental/investigational treatment.  In such cases, not only must the organization and the reviewer considered everything covered by the previous standard, but also any medical research and peer-reviewed literature that might bear on the question of the efficacy of the proposed treatment.  The difference here is that looking at medical research is something the reviewer might do a medical necessity case, but might not if the clinical criteria are sufficient.  For these cases, the reviewer must consider research literature.

Management Tips

For reasons not entirely clear to us, URAC draws a distinction between "effectiveness" and "efficacy".  We won't go into the details here, other than to say it would appear to our eyes that, even if the terms are distinct, URAC seems to be defining them backwards. We recommend boiling the assessment at down to one of whether the proposed treatment or drug is likely to work for this patient.

Make sure that your policy and procedure dealing with this type of case is utterly clear that research must always be consulted; reliance solely on existing criteria will not suffice.

URAC Accreditation Tips

The two elements of this standard are weighted 4 and 3.

For the desktop review, submit your policy and procedure for experimental/investigational reviews, along with any form letters or audit templates.

The on-site reviewer will conduct interviews of the medical Director, staff members, and to peer reviewers, as she will for the previous 10.  Also, if her selection of case files includes experimental/investigational reviews she will look for evidence that the standard was followed in those files.

The Basics

To the extent that state and federal regulations and your organization's contracts allow, under this standard your organization and the reviewer must consider the following:

• the patient's medical records;
• attending provider's recommendations (see the review request);
• health plan coverage terms;
• documentation assembled before the case was sent to independent review, including previous determinations (if allowed by regulation);
• relevant information submitted by the stakeholders;
• the criteria or policy used by the plan (documented either in the case file or in contracts or communications between your organization and the client); and
• any clinical practice guidelines, private or regulatory, that bear on the independent review.

Management Tips

The standard does not apply to experimental/investigational reviews. Not only should you have a policy and procedure that specifically require us to the elements of the standard to be considered in every case, but we recommend that you have sample letter templates that guide the reviewer from the required elements.

URAC Accreditation Tips

Three of the elements are mandatory; the rest are worth three points each.

For the desktop review, submit both the applicable policies and procedures and any template letters or audit sheets.

The on-site review for this standard will involve interviews with the compliance officer, medical director and members of the staff.  In addition, the telephone calls with the two peer reviewers mentioned earlier will address compliance with the standard.  The reviewer also will use her analysis of the 30 randomly selected case files to assess your organization's compliance with the standard.  She will be looking for documentation that all of the elements required by this standard to be considered have been included in the files

The Basics

Under this standard, your organization must implement the selection criteria from the previous standard and provide each reviewer with file with the necessary information to conduct the review.    

Management Tips

The standard is not prescriptive: it allows you to define the process for getting that information to the reviewer. However, the process must be clearly described in your policy and procedure and your staff members must follow that approach.  In the your policy should address the question of how you will obtain additional information for the reviewer if the initial batch of information is insufficient.

URAC Accreditation Tips

The element requiring that you implement the previous standard is mandatory.  The other element is worth two points.

All you need to submit for the desktop review of the policies and procedures for case assignment and case file transmission.

During the on-site review, the reviewer will interview and observe your staff members in action as they distribute case files to the selected reviewer.  In addition, the case files that will be reviewed during the on-site review should document the transmission of the case files.

The Basics

This standard establishes the minimum criteria for the qualification of your organization's reviewers:

• active clinical license;
• Board certification (where appropriate);
• clinical peer of the attending provider;
• the issue under review is within the reviewer's scope of licensure;
• five years of clinical experience; and
• the ability to evaluate alternative treatments to the one proposed.

The standard also requires that your organization have a P&P describing how many reviewers you should have in your panel. Make sure you know what your organization's criteria are in this regard.

Your best preparation for the URAC review of this standard is to be familiar with your organization's policies and procedures for reviewer qualifications and selection.  In addition, be sure you know if any regulations shape how your organization handles these issues.

Management Tips

Begin with a policy and procedure that clearly and explicitly addresses all of the elements of the standard.  The policy must make it absolutely clear that your organization has control over reviewer selection in two respects: inclusion on the panel of reviewers and selection for the review of a particular case file.  If regulatory guidelines influence either your list of criteria for selection process, make sure you cite those regulations in your policy and procedure both for your organization's sake and for the URAC reviewer's sake.

Pay particular attention to the credentialing requirement implied by this standard.  As is the case with all clinicians who are required to be licensed and or certified that come under the scope of URAC's standards, verification of licensure and certification must be primary source verification. 

The standard also vaguely requires that you have criteria for the number of reviewers. Historically, this has seldombeen enforced, but has been enforced with increasing frequency of late. In the absence of any guidance from URAC as to how to approach the "numbers" issue, you have a lot of flexibility about how you go about this. Make sure you have a P&P that sets forth criteria for the number of reviewers and what steps your organization will take should your numbers drop below the number required by your criteria.

URAC Accreditation Tips

Three of the elements of the standard (licensure, clinical peer, and scope of licensure encompasses the issue) are mandatory elements.  The remainder are worth either three or four points each.

For the desktop review, submit policies covering two key issues: credentialing of reviewers and selection for a particular case.

The on-site reviewer will both talk with your credentialing staff members and examine credentialing files for primary source verification.  In addition, many reviewers also will examine qualifications for the reviewers in each of the 30 randomly selected case files. finally, scratch that Finally, the reviewer will interview to members of your reviewer panel.  Telephonic interviews are fine.