The Basics

This standard sets forth a group of requirements for your PBM's communications processes.

First, it requires that you have policies and procedures to address the timeliness of responses to communications that you receive by means other than telephone.

Second, if your PBM performs clinical triage, you must have a clinical staff person who responds to clinical communications from consumers by:

• directly answering the clinical communication; or
• receiving a direct transfer from a non-clinical member of your staff; or
• taking no more than 30 minutes to respond to clinical communications in the event of the clinical staff person is not immediately available.

Third, in the event a clinical communication is not answered directly by a staff person, your PBM has a process to instruct the consumer (either with a recording or a live person) to choose at least one of these options:

• hang up and dial 911 if it is an emergency; or
• remain on hold for the next available clinical staff person; or
• leave a message for the clinician.

All of these will need to be spelled out in a policy and procedure, so make sure that you are aware of which policy and procedure your organization is using to comply with the standard.

Management Tips

You will need to have two kinds of documentation for this standard: a comprehensive policy and procedure that contains all of the elements of this standard and documentation of the implementation of the standard.  Examples of implementation include:

• copies of automated operator or voice response unit scripts;
• a reporting mechanism so that you can summarize data related to telephone statistics.  

These reports also will be useful in connection with demonstrating compliance with the access and availability standard in the PHARM Core module.

URAC Accreditation Tips

The two elements addressing telephonic response are mandatory.  The element addressing communications other than by telephone is weighted 2.

For the desktop review you will need to submit a combination of the policy and procedure, telephone scripts, and reports of performance of the call center demonstrating assessment of consumer access and availability.

The on-site reviewer will examine clinical case records for evidence of compliance with the standard.  In addition, he/she will monitor call center staff to see if the standard and the organization's policies and procedures are being adhered to in the handling of consumer calls.  In addition, the reviewer likely will examine quality management committee minutes and reports to the QMC regarding how your organization monitors clinical staff response time frames.  In addition, the reviewer is likely to ask for QM audit reports.

The Basics

This standard requires your organization to provide its consumers with information about services in multiple formats, such as the Internet, live presentations, video, e-mail, and telephonic.  The key here is assuring that all of your consumers have access to all relevant information, regardless of education level, language obstacles, or whether they have access to a computer.

Management Tips

While it is possible to imagine an extreme interpretation of the requirement that you reach out to "all" of your consumers, URAC takes a pragmatic approach, allowing you to fill in any gaps in your communications mechanisms by providing telephonic access to assists for consumers who don't receive or understand information you send out through other media.

URAC Accreditation Tips

This standard is weighted 4.

For the desktop review, submit the applicable P&Ps and no more than three examples of how you have implemented the P&Ps.

The onsite review will involve a demonstration of the consumer portal, an examination of sample print materials, and a review of selected consumer records.

The Basics

This standard sets forth performance requirements for the handling of in-bound calls:

• speed-of-answer averaging less than 30 seconds
• average abandonment rates being less than 5 percent.  

It is important at the outset to note that this standard will not apply to PBMs -- only those that are required by contract to provide call centers. 

Management Tips

Interestingly, there are some pretty specific "requirements" that are found only in the interpretive materials, not in the standard itself.  Make sure your P&P addresses all of them -- not just the contents of the standard.  For example,

• The average speed of answer is reported at least monthly and analyzed at least quarterly.
• Incoming call speed of answer and abandonment rate is measured post automated interactive voice response. For example, if there is a pre-recorded message or greeting for the caller, the 30-second measurement begins after the message/greeting has ended.  
• Call center operations should be measured quarterly.

URAC Accreditation Tips

Each of the two elements of this standard is weighted 4.

For the desktop review, submit the applicable P&Ps.

The onsite review will center on the interview of customer service management personnel and a review of recent performance reports.

The Basics

This standard applies only to those PBMs that provide call center services to their clients.  It sets forth the minimum requirements for operating such a call center.

First, the call center must be available around the clock, every day, to provide information to consumers about:

• emergent and urgent calls;
• questions of the clinical nature;
• processing of claims;
• benefit;
• submitting claims;
• payment of claims.

Second, for at least 12 hours each day during business days in the time zones in which the PBM operates, the call center must be available to provide:

• services to pharmacies; and
• services to physicians and other prescribers.

Finally, the call center must have the capacity to provide information about:

• benefits (co-payments and deductibles);
• pharmacies in the PBM's network;
• claims payment, submission, and processing;
• benefit/eligibility coverage;
• the drug utilization management and appeals processes; and
• how to submit complaints to the PBM.

Management Tips

If your PBM operates in multiple time zones, the requirements of the standard applies to all time zones in which you have at least 2% of your consumers.  The policies and procedures that you develop to comply with the standard should be fully integrated with policies and procedures that help support evidence that you comply with the access and availability standards from the PHARM Core module.  

Note that it is perfectly fine to use interactive voice response (IVR) technology in your call center.

URAC Accreditation Tips

15 elements in this standard vary in weight from 2 all the way up to mandatory.  Most elements carry a weight of 4.

For the desktop review, it will be sufficient to submit your call center policies and procedures.

The on-site reviewer will interview management personnel in the customer service department.  In addition, he/she is likely to listen in on telephone calls and may even call the call center during off hours to confirm that it is complying with the access standards.

The Basics

This standard addresses a situation where a consumer needs a drug that would otherwise be excluded by his or her benefit plan, but still should get the medication.  It addresses situations like natural disaster, lost supplies, prescriptions needed before a long journey, or damaged medications.  The standard requires that your organization have a clear policy and procedure that allows for such exceptions and describes precisely how they are to be handled so that the consumer is not without needed medication.

Management Tips

Writing a policy and procedure to cover this requirement is the easy part.  The more challenging part is to make sure that the appropriate customer service and other staff members are adequately trained on how to handle these unusual circumstances.  Therefore, work closely with your training department to make sure that your policies and procedures are fully implemented.  It is also important to remember that while most of the situations that arise under this standard will be on a case-by-case basis, in some instances, notably natural disaster, you may be dealing with many affected consumers at one time.  Make sure your policies and procedures are sufficiently robust to address such a situation.

URAC Accreditation Tips

This is a mandatory standard.

The initial documentary submissions should include your policies and procedures for refills, as well as any script that you have developed for customer service Representatives to implement those policies.  In addition, if you have regulations at the federal or state level that address these issues, be sure to include them in your submission.

The reviewer will interview of customer service staff and the compliance officer to assess understanding of how your organization complies with the standard.  In addition, the reviewer's examination of your complaint log may also lead to an inquiry about the implementation of the standard in the event that complaints reveal that you have not fully implemented your policies and procedures.

The Basics

This standard, which applies only if your organization is contracted to provide post-enrollment consumer information, requires your organization to have the capacity to let your consumers know about a variety of resources, both information and customer assistance.  The list of resources you are required to provide include:

• Provider directory (including network, specialty, and mail order pharmacies)
• Information about benefits (which categories are covered, which categories are not covered)
• The consumers' financial responsibilities (e.g., deductibles, co-pays, etc.)
• Options the consumer might have regarding prescription benefits
• Evidence-based information regarding common ailments and their treatments
• Information to help consumers in a variety of interactions, like how to factor finances into pharmacy benefit decisions
• How to get help via email, telephone, or in-person
• If your organization offers generic and/or mail service programs, the materials must provide consumers with information about those programs.

Management Tips

URAC doesn't tell you how to deliver the information, but your mechanisms for delivering that information should be appropriate to your audience.  Don't worry about communication "upstream" to the employer/plan/purchaser of your PBM's services.  This standard is all about your consumers and the information you provide to them.

You should have policies and procedures which specifically outline how your organization will get the required information to consumers.  Remember, it is not sufficient that your organization does all these things, but also that you have a P&P that describes how you are going to do it.

We also recommend standardizing your documentation of consumer communication, such as template consumer letters and standard post-enrollment consumer informaction packets.

URAC Accreditation Tips

Each element of this standard is weighted 4 except the one addressing generic and mail order programs, which element is mandatory.  

For the document submission, submit:

• The applicable P&Ps
• A portion of your provider directory
• A screen-shot of a consumer information page from your website
• Any employee training materials covering consumer communications
• Template letter to consumers

For the onsite review, in addition to interviewing your customer service representatives, the reviewer will look at your printed and online consumer information materials.

The Basics

This standard, which applies only to materials sent to consumers enrolled in the PBM program, requires that your organization monitor those materials for accuracy and changes them where necessary to assure that accuracy.  This ongoing monitoring should be done in connection with information about

• participating pharmacies;
• the formulary; and
• benefits.

This standard makes more specific a general requirement covered by a standard in the Pharm Core module.

So, if changes in your network, formulary, or benefits occur, you'll need to have one or more mechanisms in place inform consumers about those changes in a timely fashion (which often will mean letting them know before the changes go into effect).  

Management Tips

URAC doesn't prescribe the means by which you must let consumers know of changes, but the reviewer will expect that it make sense in the context of your particular organization and the make-up of its client- and consumer-base.

The communications plan (or P&Ps) discussed in the applicable Pharm Core standards should be specific enough to cover the requirements of this standard.  

URAC Accreditation Tips

Each element of this standard carries a weight of 4.  

The AccreditNet submission should include the communications plan/P&Ps and sample communications advising consumers of changes in the formulary or benefit structures.

The Basics

This standard requires that your organization implement mechanisms to make sure that your marketing activities do not misrepresent:

• information about benefit plans
• your organization's provider availability and accessibility (e.g., the contents of your provider directory, the extent of your service area)
• plan coverage (information about what conditions are covered)
• administrative requirements
• anything you require of consumers who are navigating your medical management systems

These communications mechanisms must include training of any employees and/or consultants (agents, brokers) who represent the organization's services to potential and actual clients and consumers.  

Management Tips

It is important that your marketing documentation addresses each of the above five components of this standard.  For example, in your training documentation showing that your staff and agents have been trained, make sure that you separate out the elements of the training into benefits, providers information, coverage, administrative requirements, and medical management.  

URAC Tips

Three of the elements are mandatory, and two are weighted 4.

For the desktop review, submit your P&Ps, training documentation (manuals, agendas, attendance logs, and 1 or 2 samples of marketing documentation.  Make sure you keep the number of documents to a maximum of 9.

It may be the case that one or more lines of business have no marketing associated with them (e.g., Medicaid in some states for some plans).  Explain this in the notes accompanying your marketing P&Ps in AccreditNet.

During the onsite review, the reviewer will interview marketing staff members about how the organization's P&Ps on this topic are implemented.  In addition, during the reviewer's visit with customer service representatives, he/she may ask the CSR to demonstrate that the CSR has access to accurate information about all the elements of this standard.

The Basics

This standard, which applies only to materials sent to consumers enrolled in the PBM program, requires that your organization monitor those materials for accuracy and changes them where necessary to assure that accuracy.  This ongoing monitoring should be done in connection with information about

• participating pharmacies;
• the formulary; and
• benefits.

This standard makes more specific a general requirement covered by a standard in the Pharm Core module.

So, if changes in your network, formulary, or benefits occur, you'll need to have one or more mechanisms in place inform consumers about those changes in a timely fashion (which often will mean letting them know before the changes go into effect).  

Management Tips

URAC doesn't prescribe the means by which you must let consumers know of changes, but the reviewer will expect that it make sense in the context of your particular organization and the make-up of its client- and consumer-base.

The communications plan (or P&Ps) discussed in the applicable Pharm Core standards should be specific enough to cover the requirements of this standard.  

URAC Accreditation Tips

Each element of this standard carries a weight of 4.  

The AccreditNet submission should include the communications plan/P&Ps and sample communications advising consumers of changes in the formulary or benefit structures.

The Basics

Pharm Core 22 requires that your organization implement a mechanism to inform both consumers and your clients of consumer rights and responsibilities.  Specifically, that mechanism needs to address at least advising them on how to obtain services and how to submit a complaint or appeal.

First, let's distinguish consumers and clients.  URAC defines "consumers" as follows: "An individual person who is the direct or indirect recipient of the services of the organization.  Depending on the context, consumers may be identified by different names, such as “member,” enrollee,” “beneficiary,” “patient,” “injured worker,” “claimant,” etc."  URAC defines "client" as "A business or individual that purchases services from the organization."  

It is entirely possible that the PBM not only does not handle communications with consumers at all, but also provides no consumer information to the client.  It's quite clear that in such cases, the standard does not apply.  In such cases, the organization mostly for consumer inquiries back to the client.

Management Tips

What managers need to understand about this standard is that your policies and procedures must describe the mechanism for providing information to consumers and clients about your organization's services and the complaint and appeal process.  It will not be sufficient to demonstrate to your act would provide consumers and clients this information.  You will need to have a policy and procedure that describes how you should do it.  In addition, you should have template letters of "bills of rights" to provide consumers.

URAC Accreditation Tips

Both elements of this standard have a weight of 4.

For the desktop review, your documentation should include not only your policy and procedure, but also documentation showing how you implement that policy and procedure, such as a Consumer's Bill of Rights, a portion of your member handbook, or a template of a consumer letter that describes consumer rights.

During the on-site review, compliance with this standard will be assessed primarily through interviews with both management and staff members charged with providing consumers with this information.  It will therefore be very important that preparation for the on-site review includes letting customer service representatives know that there are likely to be asked about the requirements of the standard when the reviewer tours the customer service department.