Concurrent Review

Health Plan, Version 7.1 P-HUM 19 - Concurrent Review Time Frames


The Basics

This standard sets forth time frames for the conduct of concurrent review.  Concurrent review is UM conducted either in the midst of treatment (in-patient or out-patient) and/or while he/she is in the hospital.  The basic rule is that, if the UM organization intends to terminate or reduce a previously approved course of treatment or hospitalization that is underway, it should give the patient enough time to request a review of the decision and get a decision before the organization implements the decision.

That is straightforward enough.  However, the challenge comes in when the patient asks for an extension of that course of treatment or hospital stay.  In this regard, the standard itself is not written particularly well, as it leaves out certain scenarios.  A clarifying comment that URAC posted in March 2009 is a better source for understanding the time frames than the standard itself.  The time frames depend on two things -- whether the request is for urgent care, and whether it is received at least 24 hours before the certification expires.  Here's how it breaks down:

  • If the request for extension is received more than 24 hours before expiration:
    • If the case involves urgent care,  notification must be within 24 hours of receipt of request
    • If the case involves non-urgent care, notification must be within 72 hours of receipt of request
  • If the request for extension is received less than 24 hours before expiration, regardless of the urgency of the care, notification must be within 72 hours of receipt of the request

 

Management Tips

Again, the primary management role is to make sure the P&P is clearly written and the staff well-trained on the time frames.  

URAC Accreditation Tips

All the elements of the standard are weighted 4.

The required documentation is relatively straightforward: a policy and procedure describing your process, and a sample template of a written notice to the patient.  The on-site review, while straightforward, is substantially more rigorous: the reviewer will go through case files to make sure that you are meeting all of these timelines.

HUM - 19 - Concurrent Review Time Frames


The Basics

This standard sets forth time frames for the conduct of concurrent review.  Concurrent review is UM conducted either in the midst of treatment (in-patient or out-patient) and/or while he/she is in the hospital.  The basic rule is that, if the UM organization intends to terminate or reduce a previously approved course of treatment or hospitalization that is underway, it should give the patient enough time to request a review of the decision and get a decision before the organization implements the decision.

That is straightforward enough.  However, the challenge comes in when the patient asks for an extension of that course of treatment or hospital stay.  In this regard, the standard itself is not written particularly well, as it leaves out certain scenarios.  A clarifying comment that URAC posted in March 2009 is a better source for understanding the time frames than the standard itself.  The time frames depend on two things -- whether the request is for urgent care, and whether it is received at least 24 hours before the certification expires.  Here's how it breaks down:

  • If the request for extension is received more than 24 hours before expiration:
    • If the case involves urgent care,  notification must be within 24 hours of receipt of request
    • If the case involves non-urgent care, notification must be within 72 hours of receipt of request
  • If the request for extension is received less than 24 hours before expiration, regardless of the urgency of the care, notification must be within 72 hours of receipt of the request

 

Management Tips

Again, the primary management role is to make sure the P&P is clearly written and the staff well-trained on the time frames.  

URAC Accreditation Tips

All the elements of the standard are weighted 4.

The required documentation is relatively straightforward: a policy and procedure describing your process, and a sample template of a written notice to the patient.  The on-site review, while straightforward, is substantially more rigorous: the reviewer will go through case files to make sure that you are meeting all of these timelines.

WCUM - 19 - Concurrent Review Time Frames


 

The Basics

This standard sets forth time frames for the conduct of concurrent review.  Concurrent review is UM conducted either in the midst of treatment (in-patient or out-patient) and/or while he/she is in the hospital.  The basic rule is that, if the UM organization intends to terminate or reduce a previously approved course of treatment or hospitalization that is underway, it should give the patient enough time to request a review of the decision and get a decision before the organization implements the decision.

That is straightforward enough.  However, the challenge comes in when the patient asks for an extension of that course of treatment or hospital stay.  In this regard, the standard itself is not written particularly well, as it leaves out certain scenarios.  A clarifying comment that URAC posted in March 2009 is a better source for understanding the time frames than the standard itself.  The time frames depend on two things -- whether the request is for urgent care, and whether it is received at least 24 hours before the certification expires.  Here's how it breaks down:

 

  • If the request for extension is received more than 24 hours before expiration:
  • If the case involves urgent care,  notification must be within 24 hours of receipt of request
  • If the case involves non-urgent care, notification must be within 72 hours of receipt of request
  • If the request for extension is received less than 24 hours before expiration, regardless of the urgency of the care, notification must be within 72 hours of receipt of the request

 

Management Tips

Again, the primary management role is to make sure the P&P is clearly written and the staff well-trained on the time frames.  

URAC Accreditation Tips

Each element of this standard carries a weight of 4.

The required documentation is relatively straightforward: a policy and procedure describing your process, and a sample template of a written notice to the patient.  

The on-site review, while straightforward, is substantially more rigorous: the reviewer will go through case files to make sure that you are meeting all of these timelines.

 

HUM - 19 - Concurrent Review Time Frames


The Basics

This standard sets forth time frames for the conduct of concurrent review.  Concurrent review is UM conducted either in the midst of treatment (in-patient or out-patient) and/or while he/she is in the hospital.  The basic rule is that, if the UM organization intends to terminate or reduce a previously approved course of treatment or hospitalization that is underway, it should give the patient enough time to request a review of the decision and get a decision before the organization implements the decision.

That is straightforward enough.  However, the challenge comes in when the patient asks for an extension of that course of treatment or hospital stay.  In this regard, the standard itself is not written particularly well, as it leaves out certain scenarios.  A clarifying comment that URAC posted in March 2009 is a better source for understanding the time frames than the standard itself.  The time frames depend on two things -- whether the request is for urgent care, and whether it is received at least 24 hours before the certification expires.  Here's how it breaks down:

  • If the request for extension is received more than 24 hours before expiration:
    • If the case involves urgent care,  notification must be within 24 hours of receipt of request
    • If the case involves non-urgent care, notification must be within 72 hours of receipt of request
  • If the request for extension is received less than 24 hours before expiration, regardless of the urgency of the care, notification must be within 72 hours of receipt of the request

 

Management Tips

Again, the primary management role is to make sure the P&P is clearly written and the staff well-trained on the time frames.  

URAC Accreditation Tips

All the elements of the standard are weighted 4.

The required documentation is relatively straightforward: a policy and procedure describing your process, and a sample template of a written notice to the patient.  The on-site review, while straightforward, is substantially more rigorous: the reviewer will go through case files to make sure that you are meeting all of these timelines.

URAC UM 19 -- v. 5.1 Proposed Revision -- Concurrent Review Timeframes


As I noted in an earlier post, the current HUM 19, prescribing timeframes for concurrent review, fails to address situations where the patient or provider request an extension of a previously approved course of treatment in cases not involving urgent care.  URAC's proposed revisions to the HUM standards fail to propose any substantive change in this standard.  This is an easy fix, it seems to me, so I just now sent URAC this comment at its web page for submission of public comments on these standards:

URAC proposes no changes to the standard language of HUM 19.  I respectfully suggest that this is an appropriate time to address a gap in this standard. 
It currently reads as follows:
For concurrent review, the organization adheres to the following time frames: (Primary)
(a) For reductions or terminations in a previously approved course of treatment, the organization issues the determination early enough to allow the patient to request a review and receive a decision before the reduction or termination occurs; and (Primary)
(b) For requests to extend a current course of treatment, the organization issues the determination within: (Primary)
(i) 24 hours of the request for a utilization management determination, if it is a case involving urgent care and the request for extension was received at least 24 hours before the expiration of the currently certified period or treatments; or (Primary)
(ii) 72 hours of the request for a utilization management determination, if it is a case involving urgent care and the request for extension was received less than 24 hours before the expiration of the currently certified period or treatments. (Primary)

The gap in this standard is this: it does not address requests for extension of a current course of treatment in non-urgent cases. 

Subsection (a) addresses all reductions and terminations in a previously approved course of treatment, without regard to whether it is a case involving urgent care.  On the other hand, Subsection (b), which deals with patient/provider requests to extend a current course of treatment, addresses only cases involving urgent care.
 
What happens, then, where a patient/provider requests an extension in a case that does not involve urgent care?  On this subject, the standard is silent.  And yet, it is not inconceivable that such a request could be made in a non-urgent situation, as in situations like physical therapy.

I recommend that the standard be amended to read as follows:
HUM 19

For concurrent review, the organization adheres to the following time frames: (--)

(a) For reductions or terminations in a previously approved course of treatment, the organization issues the determination early enough to allow the patient to request a review and receive a decision before the reduction or termination occurs; and (4)

(b) For requests to extend a current course of treatment, the organization issues the determination within: (4)

(i) 24 hours of the request for a utilization management determination, if it is a case involving urgent care and the request for extension was received at least 24 hours before the expiration of the currently certified period or treatments; or (--)

(ii) 72 hours of the request for a utilization management determination, if it is a not case involving urgent care and the request for extension was received at least 24 hours before the expiration of the currently certified period or treatments; or (--)

(iii) 72 hours of the request for a utilization management determination, if the request for extension was received less than 24 hours before the expiration of the currently certified period or treatments. (--)

From my conversations with experienced reviewers, I believe this is, in fact, the way reviewers are addressing this issue already, and therefore would not involve a change in policy.

I do hope that the URAC Standards opportunity takes advantage of this opportunity to make an easy fix to a slightly broken standard.