The Basics

This standard sets for the minimum requirements for your appeals records:

• Patient name
• Name of the consumer or prescriber
• Copies of all patient correspondence
• Actions taken and the dates they were taken, including decisions, correspondence, and resolution
• Minutes from any appeal proceedings
• The name and credentials of the appeals reviewer for each case
• The specific clinical review criteria upon which the non-certification was based

Management Tips

Note that this standard applies not only to the records themselves, but to the Appeals P&P.  In other words, your P&P needs to be explicit about your appeals record-keeping practices.  

URAC goves you flexibility about these records and their storage -- electronic and paper are both fine.  

URAC Accreditation Tips

All five elements of this standard are weighted 4.

The Appeals P&P and any logs containing the required information should be submitted for desktop review.

The onsite reviewer will look at your log and your case files to verify compliance with this standard.

The Basics

This standard prescribes the minimum requirements for the written notice of an adverse appeal decision (one upholding the initial denial of the request for certification):

• It must be sent to the patient and ordering provider or facility
• It must state the principal reasons for the decision
• It must state that your organization will provide the clinical rationale underlying decision in response to a written request
• It must describe any additional appeal mechanisms and how to access them, if they exist

Management Tips

See the earlier standard on the notice of denial of certification for a full discussion of the principal reason and clinical rationale issue.  The same issues that apply to that letter apply to this letter.  Make sure the case files contain the written notice and that it is dated.

URAC Accreditation Tips

The three elements of the standard are weighted 4.

Again, the appeals P&P and applicable templates are what you submit to AccreditNet.

The onsite reviewer will focus on appeals case files and staff interviews.

The Basics

This standard requires that the written notification of your standard appeal the decision be sent within 30 calendar days of your organization's receipt of the request for an appeal.  That receipt of the request for appeal is when the organization's mailroom first receives the request, not necessarily when the drug utilization management department receives it.  That notice needs to go to both the patient and the ordering provider or treating facility.

Management Tips

As with expedited appeals, the clock starts ticking when the request for appeal first hits your organization, not your department.  That means any part of your organization, including a call to the customer service department, or a letter to a mail room.  All delays in getting that request into the right hands in the DrUM department count against the time frame embodied in this standard.  Date-stamping, therefore, becomes very important.

Make sure your appeals tracking mechanism can distinguish between expedited and standard appeals.

URAC Accreditation Tips

This standard is mandatory.

Submit the appeals P&P and template appeals correspondence at the desktop review stage.

The onsite reviewer will look at your appeal tracking log, select a certain number of files, and review them to make sure you comply with the time frame required by this standard.

The Basics

This standard's purpose is to establish time frames for notification of the patient and provider in the event of expedited appeals.  There are two of them:

• 72 hours from the request to a verbal notification of the appeals decision
• 3 calendar days from the verbal notification to a written notification of the appeals decision

The 72-hour verbal notice need go only to the requesting party, whether it be the prescriber or the patient.  Only the written notification needs to go to both the consumer and the provider.  

URAC defines expedited appeal as any appeal in a case involving any situation in which applying normal time standards would threaten the life or health of the consumer or the ability of the consumer to regain maximum function or would subject the patience to severe pain that can't be adequately managed without the requested care.

Management Tips

Make sure your P&P on the topic is clear that the clock starts ticking on these time frames when the request to initiate the appeal is made.  that initiaion happens regardless of whether the request is in writing or via telephone.  Note, too, that the clock starts on written notification when the request lands in the mail room or receptionist's desk, not the UM department.

It will be particularly important that your appeal record system can capture:

• the date and time the organization received a request for appeal (date- and time-stamping will be helpful);
• the date and time of the initial notification; and
• the date and time of the written notification.

URAC Accreditation Tips

This standard is mandatory.

Again, the desktop submission is only the P&P and sample correspondence.  

The onsite review will focus on the case files of expedited appeals.

The Basics

This standard establishes to be minimum requirements for the health professionals who conduct appeals from non-certification decisions.  At a minimum, such professionals must:

• be either a licensed physician, pharmacist, or other licensed health care professional;
• be board certified (if applicable);
• be in the same or similar specialty as typically manages the medical condition, procedures, or treatment under review;
• neither be the person who made the original decision not to grant certification nor a subordinate of that person.

Your organization may have its own panel of appeals reviewers, or it may refer all such appeals to an independent review organization ("IRO").  Naturally, the standard applies only for those appeals that your organization handles for its clients.  Many clients retain the rights to handle the appeals themselves, and therefore remove your organization's need to comply with the standard for those appeals.

Management Tips

Unfortunately, this standard is more confusing than it might initially appear.  The main confusion arises out the very real possibility that the appeal reviewer is a pharmacist, as permitted by subsection (a), and yet required to be in a "similar specialty that typically manages a medical condition, procedure, or treatment," as required by element (d).  URAC has a history of giving great deference to the treating physician about the specialty of the person conducting the appellate review.  Therefore, if your organization typically has pharmacists conducting the review on appeal, you also should be fully prepared to refer to the appeal to a physician specialist, should the prescriber request that such a professional review the appeal.  An even safer approach would be to refer all appeals to a URAC-accredited IRO.

URAC Accreditation Tips

All of the elements of this standard are mandatory except for the board certification requirement, which is weighted 3.

For the desktop review, you should submit not only the applicable policy and procedure, but also job description of a health professional that conducts appeals and a sample template of correspondence related to appeals (such as the denial of certification written notification).

During the on-site review, the URAC reviewer will select 30 appeals files from your appeals law.  He/she will examine those files for evidence that appropriately qualified healthcare professionals are performing the review on appeal.  You should also be prepared to present the full list of names and specialties of appeal reviewers, along with credentialing information about the licensure and board certification of each.

The Basics

This standard adds four requirements for your organization's DrUM appeals process:

• The patient and/or provider(s) may submit additional information in their effort to overturn the original denial of certification
• Your organization must take all that information, plus all the information originally submitted, into account as it considers the appeal
• The appeal must be reviewed by a licensed health professional (physician or otherwise) who is in the sort of specialty as typically manages the medical condition, procedures, or treatment under review
• Your organization must go along with a decision by the appeal reviewer to overturn a previous denial of certification, although it does have the option to pay even if the reviewer upholds the denial

Management Tips

Make sure your P&P is clear on the point that these appeals standards refer only to appeals from denials of requests for certifications.  Administrative denials are not the subject of this or any of the UM appeals standards.

Some organizations contract with an IRO to perform the review function.  Contracting with a URAC-accredited IRO will save a substantial amount of headaches related to delegation oversight.

Read carefully the next page, about DrUM 23, for more information on the qualifications of the appeals reviewer.

URAC Accreditation Tips

All four elements of this standard are mandatory.

As in most of the other appeals standards, you'll be fine submitting only the applicable P&P and template correspondence regarding appeals rights.

The onsite review will focus on a review of case files of appeals of denials of certification.

The Basics

This is the first of a series of standards that require the establishment and maintenance of a system of appeals of denials of certification requests.  This introductory standard sets forth a few general requirements for your DrUM appeals system and leaves the detailed requirements for that system to the subsequent standards.

This standard's general requirements are:

• The appeals system must address both urgent and non-urgent situations
• The appeals P&Ps must describe the appeals rights of the patient and any involved prescribers
• The appeals P&Ps must describe the time frames for each component of the appeals process
• The appeals P&Ps must be available to any requesting patient or prescriber

Management Tips

We cannot stress enough the importance of having a P&P to cover appeals and to have a system for making it available.  Here's a good way to analyze your readiness for this standard:

Are your policies and procedures describing your non-certification appeals process available upon request to any patient or prescriber rendering service?

If you answer "yes" to this question, you're only partly on your way to meeting the requirements of this standard. One more question to go:

Does your P&P say that it's available to any consumer or prescriber?

If you say "no" to this question, it's time to revise your policy.

The standard requires that you have a "formal process" for appeals of non-cert decisions.  The process must be based in a P&P that (and the standard is quite explicit about this) any patient or prescriber involved in the patient's care may obtain upon request. 

Remember, in the world of URAC (or any other accreditation program), if it isn't documented, it isn't happening. So, it is not merely enough that you P&P is available, but it must say that it's available. And, you must submit this documentation with your application in order to avoid getting a comment from your reviewer asking for more documentation.

One other thing -- make sure you have an effective tracking system that allows you to retrieve DrUM denials that have been appealed, and to distinguish those cases in which the denial is upheld from those in which the denial was overturned.

URAC Accreditation Tips

All the elements are of this standard are mandatory.

For the desktop review phase, submit both your DrUM appeals P&Ps and a template for any correspondence relating to appeals.  

The onsite review will focus on the case file review and staff interviews.

The Basics

This standard requires that your organization notify the consumer of the existence of a right to appeal a non-certification decision and instructions on how to pursue such an appeal.  In addition, it appears to require that you provide similar notification to the consumer regarding exceptions.  However, the earlier standard regarding the contents of the written notification of non-certification makes no mention of describing how to pursue an exception.  URAC offers no explanation for this apparent discrepancy, so, until it issues a clarifying interpretation, it is probably safe to assume that the written notification of non-certification, as required in DrUM 14, will suffice.

Management Tips

To be safe, it may behoove you to expand your appeals policy to include a provision for providing the consumer instructions on how to pursue an exception.  While you're at it, it probably makes sense to amend your template written notification of non-certification to include such instructions.

If you have notification of appeals instructions on your website, make sure they comply with this standard and the earlier standard on written notification of non-certification.  Further, it would be useful to develop scripts for the customer service representatives so that, when asked, they can provide accurate information on how to pursue an appeal and exception.

URAC Accreditation Tips

This is a mandatory standard.

For the desktop review, submit the applicable policies and procedures, a template written notification of non-certification, and, if applicable, a screen shot of any information you have on your website about how to pursue an exception and/or appeal.

During the on-site review, the reviewer will examine your complaint logs, your appeal request tracking system, and appeals files to assess compliance with this standard.

The Basics

This general standard requires the organization to implement a process to allow consumers and prescribers an opportunity to appeal a non-certification decision.  The standard acknowledges that this appeal may be to the plan administrator and not to your organization.

Management Tips

It may be that your organization handles appeals for all non-certification decisions, no non-certification decisions, or even only some non-certification decisions for only a few clients.  Make sure your policies and procedures distinguish between what your staff is required to do when appeals are referred to the plan administrator from what the staff should do when your organization is handling the appeal itself. 

URAC Accreditation Tips

This is a mandatory standard.

The documentation you should submit includes the applicable policy and procedure, the template letter of written notification of noncertification, and, if applicable, a template client agreement under which the plan administrator retains responsibility for handling appeals of noncertification decisions.

During the on-site review, the reviewer will interview members of the drug utilization management staff to assess their understanding of the organization's policy around appeals.  The reviewer also will examine appeals case files and, within those files, noncertification letters regarding appeal rights.

The Basics

This standard requires that the organization implement policies and procedures to describe how it will handle the situation where a drug is excluded.  It relates to a client-specific request by the consumer, prescriber, or pharmacist to request the addition of an excluded drug to the defined-benefit formulary.  As was the case for exceptions, the policy and procedure may simply note that this will be handled by the benefit administrator.  However, should there be any instances in which the PBM handles a request for inclusion of an excluded drug in formulary, the policy and procedure should describe in some detail how the PBM will handle that request.

Management Tips

It is important to make sure that the policy and procedure is sufficiently explicit about how your organization will handle a request for inclusion of an excluded drug.  If there are no circumstances under which the PBM handles this, make that clear in the policy and procedure.

URAC Accreditation Tips

This standard has a weight of 2.

The only documentation necessary at the desktop review level will be the policy and procedure that applies to exclusions.

For the on-site review, make sure that the staff is trained on the organization's policy and procedure for exclusions.  In addition, the reviewer may examine committee meeting minutes, a client contract for exclusion mechanisms, and the consumer complaint log for evidence of compliance with the standard.