During the URAC onsite review, the reviewer(s), for many modules, will be selecting case files from a case log to review for evidence of the organization's implementation of its policies and procedures. This is particularly true for accreditation modules that feature patient case files, such as Health Utilization Managment, Case Management, Disease Management, and Independent Review Organizations, as well as most of the pharmacy suite modules.

One question that comes up is, "how far back can the reviewer look?" The answer depends in part on whether the organization is seeking accreditation for the first time, or instead is seeking reaccreditation:

• First-Time Applicant: The reviewer can look at files back to the date of submission of documents in AccreditNet.
• Applicant for Reaccreditation: The reviewer can look at files back to the last URAC review. This does not mean back to the last monitoring onsite review, but, rather, to the last full URAC review.

The Basics

This standard sets forth the requirements for onsite UM reviews, typically falling in the category of concurrent reviews.  It is designed to smooth the relationship between the facility and the UM organization by requiring that the reviewer:

• wear a photo ID badge (including the name of both the reviewer and the organization);
• either schedule the review a day in advance or have some other arrangement with the facility; and
• follow any reasonable procedures required by the facility (such as checking in upon arrival).  

Management Tips

As usual, the key documentation here for desktop review is a policy and procedure that requires all of what is required by the standard.

There are a couple of ways to meet the photo ID requirement.  The most obvious is for the organization to issue a photo ID that meets this requirement.  However, if the only photo ID is a driver's license, it will suffice so long as the reviewer also carries an organizational ID that has both the person's and the organization's name.

What if you don't conduct onsite reviews?  In that case, make sure your UM program document (often called a UM Program Description) specifies that the program does not include onsite reviews.  In the absence of such documentation, you may need to submit an attestation that onsite reviews are not a part of your UM function.

URAC Accreditation Tips

The element requiring the carrying of an ID is valued at 2; the other two elements carry a weight of 4.

The documentation to be submitted for AccreditNet should include the applicable P&P and, if applicable, an example of any documentation of special onsite review arrangements you have with particular facilities.

If you have a particular arrangement with one or more facilities describing the terms and conditions of the review visits, documentation of that arrangement also should be submitted with the application.  

The onsite review also will involve the examination of any special facility agreements as well as interviews -- perhaps by telephone -- of members of the concurrent review staff.

The Basics

This standard sets forth the requirements for onsite UM reviews, typically falling in the category of concurrent reviews.  It is designed to smooth the relationship between the facility and the UM organization by requiring that the reviewer:

• wear a photo ID badge (including the name of both the reviewer and the organization);
• either schedule the review a day in advance or have some other arrangement with the facility; and
• follow any reasonable procedures required by the facility (such as checking in upon arrival).  

Management Tips

As usual, the key documentation here for desktop review is a policy and procedure that requires all of what is required by the standard.

There are a couple of ways to meet the photo ID requirement.  The most obvious is for the organization to issue a photo ID that meets this requirement.  However, if the only photo ID is a driver's license, it will suffice so long as the reviewer also carries an organizational ID that has both the person's and the organization's name.

What if you don't conduct onsite reviews?  In that case, make sure your UM program document (often called a UM Program Description) specifies that the program does not include onsite reviews.  In the absence of such documentation, you may need to submit an attestation that onsite reviews are not a part of your UM function.

URAC Accreditation Tips

The element requiring the carrying of an ID is valued at 2; the other two elements carry a weight of 4.

The documentation to be submitted for AccreditNet should include the applicable P&P and, if applicable, an example of any documentation of special onsite review arrangements you have with particular facilities.

If you have a particular arrangement with one or more facilities describing the terms and conditions of the review visits, documentation of that arrangement also should be submitted with the application.  

The onsite review also will involve the examination of any special facility agreements as well as interviews -- perhaps by telephone -- of members of the concurrent review staff.

The Basics

This standard sets forth the requirements for onsite UM reviews, typically falling in the category of concurrent reviews.  It is designed to smooth the relationship between the facility and the UM organization by requiring that the reviewer:

• wear a photo ID badge (including the name of both the reviewer and the organization);
• either schedule the review a day in advance or have some other arrangement with the facility; and
• follow any reasonable procedures required by the facility (such as checking in upon arrival).  

Management Tips

As usual, the key documentation here for desktop review is a policy and procedure that requires all of what is required by the standard.

There are a couple of ways to meet the photo ID requirement.  The most obvious is for the organization to issue a photo ID that meets this requirement.  However, if the only photo ID is a driver's license, it will suffice so long as the reviewer also carries an organizational ID that has both the person's and the organization's name.

What if you don't conduct onsite reviews?  In that case, make sure your UM program document (often called a UM Program Description) specifies that the program does not include onsite reviews.  In the absence of such documentation, you may need to submit an attestation that onsite reviews are not a part of your UM function.

URAC Accreditation Tips

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

The documentation to be submitted for AccreditNet should include the applicable P&P and, if applicable, an example of any documentation of special onsite review arrangements you have with particular facilities.

If you have a particular arrangement with one or more facilities describing the terms and conditions of the review visits, documentation of that arrangement also should be submitted with the application.  

The onsite review also will involve the examination of any special facility agreements as well as interviews -- perhaps by telephone -- of members of the concurrent review staff.

An essential component of the onsite review in the DM accreditation process is a review of consumer files.  From a log of patient case files you'll provide the reviewer at the outset of the review, she will select 30 or more files to look over.  You may have these files in paper or electronic (or both) form, and that doesn't matter.  The key is that you be able to tell the reviewer where to find the various components of the file for which she is seeking.

Here is a list of the items on her checklist when she's reviewing the case files:

• Evidence of collaboration with treating provider (DM 4)
• Evidence of shared decision making, including goal setting (DM 5)
• Evidence that staff are conducting themselves properly based on their licensure status (DM 6)
• Evidence that referral patterns are consistent with DM 7
• Documentation of contacts with providers for urgent situations (DM 12)
• Documentation that rights and responsibilities have been conveyed (DM 14)
• Documentation that rights and responsibilities have been conveyed (if applicable)(DM 14)
• Documentation that eligibility criteria are implemented (DM 15)
• Demonstration of the assessment or stratification protocol (DM 16, 17)
• Verification of compliance with timelines for completing the process and conducting reassessment or re-stratification (could be through tracking system instead of consumer files)(DM 16, 17)
• Documentation of identified co-morbid conditions and individual consumer assessments in compliance with the applicant’s process (DM 16, 17)
• Documentation of compliance with time frames of DM 18
• Evidence that interventions are related to assessment/stratification data and are tracked (DM 20)

So, we recommend that, first, you conduct an audit of your case files to see that they demonstrate compliance with all these requirements.  If they do not, improve your record-keeping. 

Once you've assured that they do consistently contain this documentation, make it easy for the reviewer to find all the items in each file.  This can be accomplished in any of a number of ways, two of which are:

• sitting with the reviewer as she goes through the first few files until you are comfortable that she can find what she needs to find, and/or
• preparing a "key" that, for each requirement, tells her where in the file to look.

Remember, your reviewer is not familiar with your file system.  Make it easy for an outsider to find what she needs.