The Network standards V.6.0 has a new interpretation for the initial and recredentialing of facilities.  The change affects the eight mandatory elements, N-CR 1(b)(i), (ii), (iii), (iv) (scope of the credentialing program) and N-CR 5(b), (d), (j), and (k) (initial and recredentialing application). The requirements include the review and collection of at least the following criteria:

• State licensure information
• Medicare Medicaid certification status (via OIG), accreditation status may also be collected
• A signed and dated initial and recredentialing application with attestation

The last requirement can also be achieved by the network’s online verification and print out.

This new requirement is causing many of our clients to scramble to collect applications and requested criteria in time for the URAC onsite visit.  It is more time consuming than expected.  We suggest that the credentialing department conduct a gap analysis of its facility credentialing files to determine what the files need and to send out applications for initial (if never credentialed) and recredentialing (every 3 years). The scope of “facilities” as defined by URAC includes:

• Acute in-patient facilities such as hospitals)
• Skilled nursing facilities
• Home health agencies
• Free standing surgical centers

However, URAC will hold you to the scope described in your policy or credentialing plan.

If this seems like a big task for your organization, remember that URAC generally has been receptive to action plans for a new implementation.  Your action plans should include the date the operation change was defined, the action to complete, and the dates for the actions.  For example, an action plan might state that during a review of URAC standards on September 1, 2010, the credentialing department discovered that a new process was required for facility credentialing.  Applications and cover letters were sent out to # of facilities on September 8, 2010 to request a signed application and criteria defined in the cover letter (attach example of application and letter).  It is our intent to process 50% of all facilities by December 1, 2010 and the remaining 50% by March 1, 2011.  Hopefully these dates occur before your URAC onsite audit to ensure that you achieve full compliance with the eight mandatory elements affected by the change in N-CR 1 and N-CR 5.

Management Tips

Version 2.1 of Core amends subsection (a) of Core 16, a primary element of this 4-weighted standard. The original language was:

Prior to delegating functions to another entity, the organization: (N/A)

(a) Conducts a review of the potential contractor’s policies and procedures and capacity to perform delegated functions; (Primary)

The new, v. 2.1 language now reads:

Prior to delegating functions to another entity, the organization: (N/A)
(a) Establishes and implements a process to conduct a review of the potential contractor’s policies and procedures and capacity to perform delegated functions; (Primary)

This seems to echo what I said in an earlier blog, that even if you are doing something correctly, URAC prefers that you also have a policy and procedure that instructs you to do it correctly. In this case, this means that not only must you conduct a review of the potential conctractor's P&Ps and ability to perform the tasks you delegate to them, you must have that review be part of a process that you've implemented. This assures URAC that it is not a one-time thing, but that, instead, you'll be conducting these reviews on all future contractors.

URAC Accreditation Tips

As a practical matter, this means that your documentation must not only include evidence that you've conducted such reviews on your contractors, but also have a policy and procedure that clearly outlines that required process.

Management Tips

The change in Core 11 from v. 2.0 to v. 2.1 could not be more technical -- changing the first word from "The" to "A".  It now reads:

A senior clinical staff person:

   (a) Provides guidance . . .

   (b) Is responsible for . . .

   (c) Has periodic consultation with . . .

The only possible significance that I can imagine of this change is that it takes the heat off the senior-most clinical staff member for doing the things required by the standard -- i.e., he/she can have a less senior clinician handle these tasks.  This is suggested in Core 10 (both the old and new versions), so one might argue that this change is unneeded.  I'll not be the one arguing that, though.

URAC Accreditation Tips

Documentation to support this standard is straightforward:  job description, verification of licensure, and CV are the minimum, while a program description describing the senior clinician's roles  and documentation of activities conducted in the field by this clinician are helpful, too.

Management Tips

The changes from v. 2.0 to v. 2.1 in Core 7 (Staff Training Program) are two:

Subsection (c), a secondary element, which originally read, "The organization has a training program that includes training in URAC standards as appropriate to job functions" added the word "current" before "URAC Standards." Therefore, one can surmise that it will not be sufficient that your staff members have been trained in URAC standards at some point, but that they have been trained recently enough for that training to reflect any recent changes in standards. Since URAC almost never makes changes more frequently than every couple of years, and usually less frequently than that, you should be safe if you have your staff go through URAC training once per year.

The other change is the addition of a new primary element, now labeled (g) (and pushing the 2.0 (g) and (h) back to (h) and (i): "The organization has a training program that includes training on identification and prevention of fraud and abuse, as appropriate to job functions." Most of our clients' regulatory compliance training (already required by Core 7(d)) includes training on fraud and abuse, but this standard makes it explicit. Note, however, that this is a primary element of a mandatory standard. In other words, if you don't specifically show that your staff has been trained on this topic, you cannot achieve full accreditation.

URAC Accreditation Tips

There are three version 2.1 changes to the standard, which is a particularly with important one because it is a mandatory standard. This standard governs the organization's policies and procedures.

1. The first change, to subsection (a), narrows the required scope of the applicant's policies and procedures. In version 2.0, the organization was required to maintain and comply with written policies and procedures that govern all aspects of its operations. The new version requires only that the submitted policies and procedures govern "core business processes of its operations related to the scope of the accreditation." In other words, if you are a multidimensional organization that is seeking accreditation for only one of those dimensions, the policies and procedures that you submit to URAC need only cover the accreditation program under which you are applying.
2. The second change, to subsection (d), liberalizes the requirement regarding where the organization indicates effective dates, review dates, and the date of the most recent revision, as well as the identification of approval authority. The original version required that this information be on the policies themselves. Version 2.1 requires that this information be either on the policies or on the master list of policies and procedures that is required to be maintained under subsection (b). By making this change, URAC has harmonized the language of the standard with the interpretation that URAC's reviewers have been applying for some time.
3. Version 2.1 adds requirement that the policies and procedures must be available to members of the applicant's staff.

So what are the mandatory standards?

URAC has always had mandatory standards. However, only with version 1.0 of the Core standards developed in the early part of this decade did the current notion of “mandatory standard” emerge. Mandatory standards typically, but do not always, have to do with consumer protection. A mandatory standard is any standard that has a weight of “5”.

In order to be fully accredited, an applicant must score at least 2 out of a possible 4 points on every mandatory standard. You can only get a score of two if you pass all of the “primary” elements of a standard. Therefore, what really is mandatory is that an applicant pass all of the primary elements of all of the mandatory standards.

The mandatory standards for the Health Call Center module are:

HCC - 2 - Clinical Director Consultation
HCC - 3 - Limitations in Use of Non-Clinical Staff
HCC - 5 - Clinical Triage Staff Qualifications
HCC - 6 - Clinical Decisions Support Tool Requirements
HCC - 7 - Clinical Decisions Support Tool Documentation
HCC - 13 - Clinical Staff Response Requirements
HCC - 14 - Handling of Triage Calls
HCC - 21 - Feedback to Physician

Naturally, an applicant for HUM also will have to meet all the mandatory standards for Core, v. 2.1, posted here.

So what are the mandatory standards?

URAC has always had mandatory standards. However, only with version 1.0 of the Core standards developed in the early part of this decade did the current notion of “mandatory standard” emerge. Mandatory standards typically, but do not always, have to do with consumer protection. A mandatory standard is any standard that has a weight of “5”.

In order to be fully accredited, an applicant must score at least 2 out of a possible 4 points on every mandatory standard. You can only get a score of two if you pass all of the “primary” elements of a standard. Therefore, what really is mandatory is that an applicant pass all of the primary elements of all of the mandatory standards.

The mandatory standards for the Health Plan (v. 5.1) module are:

Network Management
P-NM 3-Provider Selection Criteria
P-NM 4-Out of Network and Emergency Services
P-NM 6-Provider Relations Program
P-NM 7-Participating Provider Written Agreements
P-NM 8-Participating Provider Written Agreement Exclusions
P-NM 18 – Participating Provider Suspension Mechanism for Consumer Safety
Credentialing
P-CR 1 – Practitioner and Facility Credentialing
P-CR 10 – Consumer Safety Credentialing Investigation
P-CR 14 –Participating Providers Credentials Monitoring

Naturally, an applicant for Health Plan accreditation also will have to meet the mandatory standards for both the Core module, found here, and the Health Utilization Module, found here. 

So what are the mandatory standards?

URAC has always had mandatory standards. However, only with version 1.0 of the Core standards developed in the early part of this decade did the current notion of “mandatory standard” emerge. Mandatory standards typically, but do not always, have to do with consumer protection. A mandatory standard is any standard that has a weight of “5”.

In order to be fully accredited, an applicant must score at least 2 out of a possible 4 points on every mandatory standard. You can only get a score of two if you pass all of the “primary” elements of a standard. Therefore, what really is mandatory is that an applicant pass all of the primary elements of all of the mandatory standards.

The mandatory standards for the Health Utilization Management (v. 5.1) module are:

HUM - 9 - Pre-Review Screening Non-Certifications
HUM - 10 - Initial Clinical Reviewer Qualifications
HUM - 12 - Initial Clinical Reviewer Non-Certifications
HUM - 13 - Peer Clinical Review Cases
HUM - 14 - Peer Clinical Reviewer Qualifications
HUM - 22 - Written Notice of Non-Certification Decisions and Rationale
HUM - 30 - Non-Certification Appeals Process
HUM - 31 - Appeals Process
HUM - 32 - Appeal Peer Reviewer Qualifications
HUM - 33 - Expedited Appeals Process Timeframe

Naturally, an applicant for HUM also will have to meet all the mandatory standards for Core, v. 2.1, posted here. 

The Basics

Core 21 requires mechanisms to assure clear communications about services to clients and consumers and protections against misleading communications.  These mechanisms must operate before a marketing piece goes out and, in addition, in a process of ongoing monitoring for accuracy.  Finally, this review must happen through an interdepartmental process.

It is important to note that even organizations that have no direct contact with consumers must comply with this standard, as it covers communications with clients, as well. 

It is also very important for everybody involved with the organization's communications to understand that this standard does not apply only to newly-developed marketing materials.  Note that subsection (d) applies to existing materials.  Therefore, not only your policy and procedure, but also your execution of that policy, must include a documented periodic review of existing marketing materials for accuracy. 

Management Tips

While the intent of this standard is to assure that the information that applicants give to consumers about their services are accurate, it is not the kind of standard about which the URAC reviewer can directly assess compliance.  In other words, it is highly unlikely that the reviewer will be able to look at a piece of marketing material and determine that it is a misrepresentation about the organization’s services. 

The only example of this kind of direct assessment of compliance with the standard that I can recall had to do with the use of the URAC logo to signify accreditation status.  One thing about which URAC is quite clear is which organizations have received accreditation and for what programs.  If you use the logo in a way that suggests the scope of your accreditation is broader than it truly is, in that case, URAC is likely both to detect it and frown upon it.  Otherwise, however, the assessment of compliance with the standard is largely a process-oriented assessment. 

URAC Accreditation Tips

The reviewer will focus his/her attention on mechanisms and processes.  Our baseline recommendations for compliance with the standard are:

• A policy and procedure that clearly describes the full array of mechanisms for communicating with consumers and clients, including those components of the processes that address assuring the accuracy of those communications;
• Documentation (meeting minutes for marketing materials review audit sheets) clearly demonstrating that the materials review process was interdepartmental;
• Documentation that all current marketing materials, whether print or electronic, have been subject to this interdepartmental review process.