For many of the URAC accreditation programs, an essential component of the onsite review is one or more file reviews.  For example, for Health Plan and Health Network, the reviewer will examine provider contracts to assess compliance with the applicable Network Management standards. Similarly, the medical management modules (UM, WCUM, CM, DM, DrUM, etc.) involve reviews of consumer case files to assess compliance with standards in each of those modules.

There are a few things to know about the file reviews:

• Files are selected in the morning of the review from a case log. Right after the opening remarks, the reviewer(s) will select files for review. They will do so from a log of the case files. Therefore, you'll need to be able to present a list to the reviewer(s) of all the cases in a particular category in the form of a case log. 
• Case logs should be separated by category. If there are several types of files to be reviewed during the onsite review, make sure you have a separate log for each type. So, if your organization seeks HUM accreditation, be sure your expedited reviews are separated from your standard reviews, and that your first-level reviews are in a separate log from your appeals. 
• Files will be selected from the full period for which you are being assessed. If your organization is seeking reaccreditation, you'll need to be able to provide logs all the way back to your date of accreditation. If you are a first-time applicant, files can be pulled all the way back to the day you hit "submit" on your document submission to AccreditNet.
• Files must be produced within 90 minutes (and we recommend quicker). Once the URAC reviewer hands you a list of files to be pulled, she will expect the files to be back to her within 90 minutes. We have found that, if you can get them there in 60 minutes, the reviewer will be even happier (which is a state of mind in which you want your reviewer). This is true even if you keep your records off-site. If you keep records off-site, you still need to be able to produce them for the reviewer within 90 minutes. We won't begin to list the ways you might end up doing it, but you should address this issue early in the process, as the logistical challenges may be substantial. The only exception to this rule is Health Plan/Network provider contracts. If you keep them off-site, you may ask the reviewer to preselect contracts for review before she shows up at your offices, giving you a few days' lead time to pull them. Do not expect this kind of leaway for UM, CM, DM, or other medical management patient case files. URAC's rule on this is very firm.

The Basics

This CMS standard provides:

The MAO’s written contracts with any entity that performs deemable activities that are delegated under its contract with CMS, must contain provisions that specify that the entity adhere to the delegation requirements in the MA regulation.  

This standard is fully implemented by the standards dealing with delegation agreements.  

URAC Accreditation Tips

The only documentation needed at the desktop stage is a sample a delegation agreement.

The on-site interview of personnel in charge of delegation oversight will ask:

• "What are the general terms of the delegate agreement? 
• How do you monitor compliance with CMS regulations?"

This standard provides:

The MAO’s written contracts with first tier and downstream entities must contain the provisions that contracting providers agree to safeguard beneficiary privacy and confidentiality, consistent with all Federal and State laws, and ensure accuracy of beneficiary medical, health, and enrollment information and records. 

The standard is fully implemented by P-NM 10:

The Basics

This standard was written to deal with the situation that might otherwise be considered delegation, as in the case where your organization contracts with a provider group that, in turn, contracts with an individual provider.  Rather than subject that relationship to all of the requirements of delegation oversight, the standard simply says that your basic agreement with the provider organization must contain a clause that stipulates that, if the organization should enter into a subcontract with another provider for participation in your provider networks, the relationship between the provider organization and that provider be subject to the terms of the contract between your organization and the provider organization.

Management Tips

This standard is likely to require special attention, as it is relatively new.  Your contracts likely do not have this clause unless they were written within the last three years.  So, make sure your current contracting policy and procedure contains this requirement.  In addition, make sure that it is included in your provider manual (and you'll see why this is important on the next page).  Finally, make sure that your current contract templates contain this clause.

URAC Accreditation Tips

This standard is mandatory.

See P-NM 7 for a description of the desktop and on-site review requirements.

The Basics

This standard provides:

An MAO may not prohibit a health care professional from advising or advocating on behalf of a patient.

In addition to the URAC standards prohibiting so-called "gag-clauses" in provider agreements, URAC supports this CMS standard with two standards, MAP-NM 5 and MAP-NM 6.  Those standards require that your organization:quotes in

• ensure that participating providers in your network provide information to their patients who are your members in a culturally competent manner; and
• provide consumers with disabilities with effective communications throughout the healthcare system.

The on-site document review will focus on making sure that the contracts with providersdo not contain gag clauses or improper definitions of utilization management.  In addition, provider complaints would be examined to see if there are any problems associated with requirements of the standards.

In addition, your organization is not required to cover, furnish, or pay for a particular counseling or referral service if your organization objects to the provision of that service on religious or moral grounds and provides consumers information, before and during enrollment, about any such constraints on the organization's coverage.  It is important, however, that your organization provides consumers with notification of the adoption of the policy within 90 days.

URAC Accreditation Tips

Documentation for the desktop review includes applicable policies procedures, provider manual, or sample provider or member newsletters.

The on-site interview will be directed at the medical director and provider relations and utilization management apartment staff, and will focus on the following questions:

• How do providers know who to contact when medically necessary care is not available within the plan? 
• What expectation does the plan have for oncologists in informing patients about their treatment options?

This CMS standard provides:

The MAO must establish a formal mechanism to consult with the physicians and subcontracted groups that have agreed to provide services regarding the organization’s medical policy, quality improvement programs, and medical management procedures.

URAC supports this standard through a combination of network management standards, reviewed elsewhere in this training, requiring a formal strategy to involve participating providers on clinical and payment related committees.  In addition, URAC's delegation standards and HUM standards encouraging communication with participating providers provide all the necessary support.  You have already received training in those that apply to your role in the organization.

The CMS standard provides:

The MAO must have written policies and procedures and a process for rules of physician participation and adverse participation decisions.

The Basics

URAC supports this standard with the provider dispute resolution standards addressed elsewhere.  The primary change to those standards for the purposes of Medicare Advantage is the requirement that a majority of the members of the appellate review panels be peers of the disputing provider (MAP-NM 1).  In addition, the organization and the contracting provider must provide written notice to each other before terminating the provider agreement without cause (MAP-NM 2).  

URAC Accreditation Tips

Documents you should submit for desktop review include applicable policies and procedures, credentialing committee minutes, provider manual, and a sample template termination or suspension notice to a provider.  In addition, be prepared to submit a list of terminated or suspended providers at this stage.

The on-site review interview will be directed at the medical Director and the members of the staff of the credentialing and provider relations departments.  Questions will include:

• What are the conditions of participation? 
• Is this in the contract language and or provider contract?
• When changes are made how and when are providers notified 
• What are some of the reasons that determine termination, suspension from the network?
• How are these instances investigates and does the credentialing committee make the determination?
• When providers are terminated or suspended from the network what is the process for investigation, notification, and appeal rights?
• Please provide example of quality of care reviews that resulted in termination and suspension. 
• Please show me the cases and documented letters.
• What are reportable event to the medical board?

This CMS standard provides:

The MAO implements procedures to ensure that members are not discriminated against in the delivery of health care services consistent with the benefits covered in their policy based on race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment. 

The URAC standard supporting this standard is MAP-AD 1.

The Basics

The standard sets forth a long list of factors that your organization may not use to deny, limit, or condition coverage or benefits:

• Mental or physical disability or condition;
• Claims experience;
• Receipt of health care;
• Medical history;
• Genetic information;
• Evidence of insurability, including conditions arising out of acts of  domestic violence;
• Disability;
• Race;
• Ethnicity;
• National origin;
• Religion;
• Sex;
• Age;
• Sexual orientation; or
• Source of payment.

Make sure you can find the organizational document(s) that explicitly implement this standard.

Management Tips

A general anti-discrimination clause will not suffice.  You need to be as specific, both in your P&Ps and in your staff training, as is the standard.

URAC Accreditation Tips

The desktop review submissions should include very specific applicable policies and procedures and/or applicable sections from the provider manual.  In addition, agendas and attendance sheets from staff orientation and training classes on this topic of anti-discrimination should be submitted.  Any other organizational documents that address anti-discrimination would be useful, too.

The on-site review interview will be targeted at the member services and provider relations staff members.  Three main questions that are likely to be asked are:

• How is antidiscrimination addressed in provider contracting?
• Did you receive any training pertaining to discrimination?
• How are members informed of their rights?               

The Basics

The CMS standard is:

The MAO must establish written standards for provider consideration of member input into the proposed treatment plan and for advance directives.

URAC Accreditation Tips

Documents to submit in the desktop review phase include policies and procedures, and any portion of the provider manual or provider newsletters that address patient involvement in proposed treatment plans and communications around advanced directives.  In addition, any medical record audits that get at this issue, as well as any member educational materials, including newsletters, would be good to submit here.

The on-site review will involve an interview of the medical director, and members of the provider relations, case management, and utilization management staff.  Questions will include:

• How are providers assisted with advance directives resources to provide members?
• What tools does the plan provide to facilitate consumer input into treatment options?
• How are members provided with information on advance directives?
• How is this information incorporated into the plan of care?
• Where in the enrollee (outpatient) record are providers required to document advance directives?

On-site document review will include an examination of the provider manual, materials concerning advance directives, and applicable member education materials.

This CMS standard provides:

All MAOs that offer CCPs must ensure continuity and coordination of care through procedures for timely communication of clinical information among contracted network providers, with the member, and with his/her designees (if applicable).

The URAC standard implementing this is MAP-CCP2.

The Basics

This standard requires that your organization have policies and teachers to assure timely communication of clinical information among the members of your provider network, and between those providers and consumers and their families.  Those policies and procedures need to include:

• mechanisms to ensure that the organization on the network path sufficient information for quality continuous patient care and quality review;
• mechanisms for appropriate and confidential exchange of information throughout the network; and
• procedures to assure consumers have timely access to records and other information regarding their health and enrollment in health plan.

URAC Accreditation Tips

Documents be included with your desktop review submissions should include policies and procedures, the provider manual, sample provider newsletters addressing coordination of care, and the results of audits of medical records.  Member newsletters and education materials might be useful submissions, as well.

The on-site interview of the medical Director, utilization management and case management staff will include questions such as:

• What are the organization policies and procedures for care coordination?
• How are providers informed about the network care coordination services?
• Are member's medical records' audited?
• What items are on the tool ( follow-up care, education in self-care, health promotion activities, & referrals for care needs?)
• What education materials does the plan provide members to assist with coordinating their care?
• What requirements does the plan set for communication between the PCP and specialist?
• Are summaries sent to the PCP?
• A member is discharged from the hospital what is the expectation of the facility to inform the member of follow-up care needs?
• How often are enrollee member records audited?
• What policies and procedures are disseminated to providers regarding documentation guidelines?