The Basics

The standard is for the special situation of a provider whose conduct is so egregious as to give rise to a well-founded concern by your medical director that the provider is posing a threat to the well-being of your consumers.  This is a very important consumer safety standard.  Not only must you are medical director be freed from the requirement of taking such a dispute through the normal, often slow, dispute resolution process, it places an affirmative requirement on him or her to handle such a situation in an expeditious manner.

The proper procedure, once the medical director concludes that the provider poses such a danger, is to suspend immediately the provider.  Then, after the suspension, your organization should conduct an expedited investigation to make sure that the medical Director's concerns were well-founded.  Finally, the dispute resolution mechanism described in the previous standards must be made available to the suspended provider.

Management Tips

The requirements of this standard must be embodied in your credentialing plan or a policy and procedure that explicitly contemplates this circumstance.  In addition, your medical director must be absolutely clear that he or she not only has this authority, but also an affirmative obligation to exercise this authority.

URAC Accreditation Tips

This is a mandatory standard, and all of the elements are primary.

For the desktop review phase, you may submit the same documentation that you submit for the previous dispute resolution standards.  

During the on-site review, this issue will come up in the reviewer's interview with the medical director.  He or she must be prepared to answer this question, as it is almost a certainty to come up.  This kind of emergency suspension procedure is fairly uncommon, so it would not be surprising if you had no documented examples.  However, if you do, we recommend that you be prepared to produce one or more examples of such an emergency suspension for the reviewer's examination.

The Basics

After a decade of dealing with provider dispute resolution accreditation standards, we have concluded that it is best to deal with them as a whole, rather than individually.  Under these standards, your organization must have a well-developed mechanism for resolving significant disputes with providers.  Typically, those providers disputes come in two categories, administrative and clinical/professional.  While it is possible that you will have a single provider dispute resolution mechanism for all of these disputes, it is more likely that your organization has chosen to provide different dispute resolution mechanisms for these two categories.  The "due process" afforded to providers in a clinical/professional dispute resolution process is more robust and expensive to administer than the required processes for administrative dispute resolution.

In any event, these standards require that your policies and procedures for provider dispute resolution clearly articulate that process in a way that providers can understand, provide for specific time frames for each step in the process, and have clear descriptions of the process by which providers may seek redress and appeal decisions made in the process.  In addition, these policies and procedures must be developed and reviewed with the involvement of participating providers no less frequently than annually.

The minimum requirements for "due process" for these two types of provider disputes are as follows:

• Clinical/professional (e.g., related to professional quality of care or conduct):
  • two levels of appeal
  • each appeals panel is comprised of at least three persons
  • each appellate panel has at least one participating provider who is not otherwise involved in network management and who is a clinical peer of the disputing provider
  • the provider may present relevant information at each level of appeal, although not necessarily in person
• Administrative:
  • the provider has a mechanism for the presentation of relevant information
  • the provider's issue will be considered by an authorized representative of the organization who was not involved in the initial decision that is the subject of dispute

Management Tips

Nearly all first-time applicants will need to modify their existing policies and procedures to accommodate these standards' requirements, particularly the requirement of having a second-level appellate panel composed of at least three people, one of whom is a participating provider who is a clinical peer of the disputing provider.

Most organizations house these dispute resolution policies and procedures within their credentialing program.  Therefore, this language probably should be in their credentialing plan or credentialing policies and procedures.

Another often-missed requirement of this set of standards is that your policies and procedures for provider dispute resolution be annually approved by participating providers.  This most frequently is met by having the standards come up for annual review by the credentialing committee, which has to review all credentialing policies and procedures in any event on an annual basis.

URAC Accreditation Tips

All of these standards carry a weight of 4, and most of the elements are primary.

For all of these standards, you should submit your applicable policies and procedures, as well as any sample correspondence associated with provider dispute resolution.  In addition, it would be helpful to submit minutes from committee meetings demonstrating provider approval of the policies and procedures, as well as any minutes from appellate panels involved in provider dispute resolution.

For the on-site review, you will be asked for a list of complaints, grievances and appeal submitted by providers over the last year.  From that list, the reviewer will select sample provider disputes to a sure that your dispute resolution in those cases was conducted according to policies and procedures and the applicable standards.  In addition, your senior staff members and medical director will be interviewed on how disputes are handled.

The Basics

The standard is intended to address the situation of "silent PPOs".  

URAC provides the following definition and explanation of silent PPOs:

[A] PPO brokers access to its provider network to other PPOs or payers without providers’ knowledge.  For example, PPO X may sell access to its provider network to PPO Y.  When an eligible person from PPO Y receives service from a physician in PPO X’s network, PPO Y takes the contract discount, although the physician never signed a contract with PPO Y.

First, if your organization does not operate a silent PPO, this standard is "not applicable."  

Second, it is important to know that this standard does not prohibit silent PPOs.  It simpler requires that you have a process for disclosing to inquiring providers how that silent PPO affects the provider.  That information can be delivered in response to one of two types of questions from the provider:

• First, the provider might be interested to know how a particular claim was paid under your silent PPO or arrangement.
• Second, the provider may want a more generalized understanding of your silent PPO arrangement by requesting a list of clients or other pairs that are entitled to any contract rate under the contract between you and the provider.

If your organization does operate a silent PPO, you will need to find the policy and procedure that describes your mechanism for responding to these two types of inquiries.

Management Tips

If you do have a silent PPO in your organization, you will need to have an explicit policy and procedure that describes how your staff members should respond to the two types of provider inquiries described in this standard.  The policy and procedure should be explicit about what types of information you will provide and who will provide it.  We recommend that you develop a standardized written response to providers who ask for your client/payer list.  In addition, your staff member should be trained in how to answer the question of how a particular claim was paid under the contract.

URAC Accreditation Tips

This standard carries the weight of 3, and its elements are secondary.

In the event of this is a non-applicable standard does you do not operate a silent PPO, you will simply submit an attestation to URAC explaining that you do not operate as a silent PPO.  If you do operate a silent PPO, submit the policy and procedure that describes your response mechanism, along with any standardized template written responses or scripts you prepare for the implementation of that policy and procedure.

During the on-site review, the reviewer will want to look at a list of payers entitled to any contract rate under your contract with participating providers.  In addition, he/she will interview managers in charge of response to provider inquiries described by this standard.

The Basics

This standard contemplates that not all of your existing contracts with participating providers contain all of the requirements of the previous several standards.  Rather than forcing your organization to go back and amend all of the extant, noncompliant participating provider agreements, URAC allows you to "fix" to these agreements by using your provider manual or other similar document that describes the relationship between your organization and the providers in your network.  So long as your provider manual contains all of the required provisions of the previous several standards, or, in the alternative, you provide instructions to your providers on how to obtain the documents that incorporated these required elements into your relationship with disputing providers, you need not go back and amend old, noncompliant agreements.  However, note that, on an ongoing basis, your new contracts do need to comply with the previous several standards.

Management Tips

The simplest way to take advantage of this standard is to make sure that your provider manual contains all of the requirements included in the previous several standards.

URAC Accreditation Tips

The standard carries any weight of 4, and its elements are primary.

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

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 carries a weight of 4, and its only element is secondary.

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

The Basics

While the previous standard described what must not be in your provider agreements, this standard prescribes what must be in your provider agreements.  It is a rather straightforward checklist:

• the names of the parties to the agreement
• minimum requirements for participating providers
• the contractual obligations of both of the parties to the contract
• events that may lead your organization to modify or terminate the provider's participation in the network
• terms regulating your organization's access to consumer medical records in the possession of the participating provider
• the healthcare services that the participating provider will provide under this agreement
• claims submission requirements and prohibitions (e.g. billing of consumers)
• provider payment methodology and fees
• a description of the provider dispute resolution mechanism
• contract term and termination procedures
• terms describing requirements regarding confidentiality of patient health information
• an antidiscrimination clause

Management Tips

Your provider contracting policy and procedure should explicitly require the elements of the standard for all new contracts.  In addition, you should conduct an audit of your present universe of contracts to get a sense of the extent of your organization's compliance with the standard.  Finally, for reasons we will explain in greater detail in a subsequent page, you should replicate nearly all of these requirements in your provider manual, whether or not that provider manual is incorporated by reference into your provider contracts.

URAC Accreditation Tips

This standard carries a weight of 4.  Most, but not all, of the elements are primary.

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

The Basics

This standard, the first of several standards dealing with contractual arrangements with participating providers, offers the simple requirement that you have written agreements with all of your participating providers.  Naturally, if your organization is contracting with the provider group, you may have a single contract with the entire group rather than each individual participating provider.  However, the underlying point of this contract remains the same: there must be a contractual relationship, embodied in a written agreement, between your organization and every provider in your network.

Management Tips

Although the interpretive materials that accompany this standard don't suggest that this is required, we do recommend that you incorporate the sentiment of this standard into a policy and procedure.  In other words, your policies and procedures should make it clear that every provider must have a corresponding contract.

URAC Accreditation Tips

This is a mandatory standard with a single, primary element.

For the desktop review, we recommend that you submit the policy and procedure that incorporates this requirement of a written agreement for every provider.  In addition, that policy and procedure should describe the contracting process and the minimum requirements of those contracts, as spelled out in the next several standards.  In addition, we recommend that you submit a template agreement, one for each category of provider in your network (e.g., primary care provider, specialist, hospital, ancillary provider).  In addition, submit a list of any significant revisions in your provider contracts over the last two years, along with the date and description of each such revision.  Finally, because your provider manual likely will be an important part of the documentation for the next several standards, we recommend that you submit it here.

During the on-site review for this and all the standards in this training section, the reviewer will use your provider manual to select at least 30 participating providers and asked to see the contracts for each.  Make sure that, when you deliver the contracts to the on-site reviewer, it is clear to which of the selected providers each contract applies.  For example, if the name of the provider that the reviewer selects is not on the face sheet of the contract (perhaps because the provider is a member of the group with which the contract is executed) a fix a Post-it note to the contract that bears the name of the provider that the reviewers selected from the provider directory.

The Basics

As a health network, your organization communicates with the providers in its network.  This standard sets forth the minimum requirements of your program of participating provider communications:

• a provider communications plan that includes:
  • new provider orientation;
  • network activity updates;
  • information about changes in fees or other contract issues;
  • guidance on getting information about such things as benefits, eligibility of members, formularies, and appeals;
  • guidance on how to obtain provider manuals and similar documents.
• mechanisms to help participating providers navigate your provider network; and
• one more means of receiving suggestions from providers about how you can provide better service.

Most organizations address the standard by developing a comprehensive provider communications plan that not only lists all these requirements, but describes in some detail how your organization meets those requirements.  Check to see if your organization has such a plan.

Management Tips

Our recommendation is that you handle the requirements of this standard by developing a comprehensive provider communications plan that includes all of the above-described elements.  Such a plan should be detailed enough so that a newcomer to your organization, asked to take up responsibility for the execution of some component of this plan, would know, in a general sense, how to do his or her job.

Standardization of your approach to communicating with participating providers could also come in the form of a standard orientation packet that your organization provides to each participating provider.  In addition, provider newsletters are useful means of meeting the requirements of the standard, particularly when developed in the context of a comprehensive provider communications plan.

URAC Accreditation Tips

This is a mandatory standard, and all of the elements are secondary.

You will have a lot of flexibility around the documents you submit in the desktop phase.  Obviously, we recommend that you start with the communications plan described above, and then submit examples of the implementation of the plan, such as provider newsletters, orientation checklists, "blast fax" communications to members of your network, etc.

The on-site reviewer will get most of his or her information about the standard from an interview of provider relations management personnel.  We recommend that, in the course of that interview, provider relations managers be prepared to show the reviewer documentary evidence of the implementation of the communications plan (provider newsletters, orientation package, etc.).

The Basics

Under this standard, your organization must implement a conscious strategy of involving participating providers, at least at some level, in the management of your organization.  In addition, that involvement must include participating providers who are relatively typical of the participating providers in your provider network.  In particular, that participation should involve including participating providers on committees that deal with clinical and provider payment issues.

Typically, a health network complies with this standard by having participating provider representatives on such committees as credentialing, quality management, and utilization management.  Some organizations rely on a multi-purpose committee designed specifically for this purpose, perhaps a physician advisory committee.

Management Tips

Naturally, it is not always easy to get robust participation by physicians and other providers in the management of your company.  If you run into such troubles, just make sure that you document your good-faith effort to recruit providers for participation in your committees.

The standard places an emphasis on participating providers from outside your organization.  Unless your network is a "staff model" organization in which all of your participating providers are employees, you will need to go outside your employee base to find providers who will meet the requirement of the standard.  Within a staff model organization, you'll need to use providers who are not in network management positions.

As is usually the case, it will not be sufficient to merely have participating provider members of committees; your policies and procedures will need to formally create such involvement.

URAC Accreditation Tips

This standard carries a weight of 3 and all its elements are secondary.

At the desktop review phase, submit documents such as 

• policies and procedures that create a role for participating providers on your committees;
• a list of all committee members including providers, making sure to identify provider credentials and relationship to the organization;
• examples of recent committee meeting minutes demonstrating actual involvement of participating providers (again, make sure the participating providers are identified in the meeting roster as non-employees).

During the on-site review, the reviewer will examine committee meeting minutes and interview the medical director about how participating providers are recruited for the organization's committees.

The Basics

With this standard, you are required to answer the question, what services do we provide, and where do we provide them?

This standard is important to URAC reviewers, because it helps them understand the nature of your network.  Are you a general healthcare services network or specialty network?  Do you provide health care services in a small region, statewide, or nationally?  The rest of the review will be guided by the documentation and answers to interview questions that you provide in connection with this standard.

Your organization likely answers both of these questions in official documents, such as marketing documents, regulatory filings, and the geo-access maps that help you manage your provider network.  Make sure you are familiar with how your organization officially answers these questions.

Management Tips

Remember, it you do not get credit for doing things that you do not document.  So, the fact that you operate in a certain area and provide certain health care services is insufficient for purposes of this accreditation process.  Rather, you need to be able to document, with official company documents, what services you provide and where you provide them.  You are allowed a good deal of flexibility in how you do this.  Your documentation might be in marketing materials, regulatory materials, internal policies and procedures or plans, or reports.

URAC Accreditation Tips

The standard carries a weight of 4, and all elements are secondary.

Your desktop review documentation is likely to be some combination of plans (business, marketing, strategic), service area maps, geo-access analyses, and regulatory filings.

The on-site reviewer will verify your compliance with the standard through an examination of your organizational documents and interviews with network management and provider relations management personnel.