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

All three elements of this standard are mandatory.

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

The elements of these standards are either mandatory or weighted 4..

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

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 two elements of this standard are weighted 4.

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 is mandatory.

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

About half of these elements are mandatory.  The rest are weighted between 2 and 4.

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

The Basics

This standard prohibits provider contracts from containing either a so-called "gag-clause" or a definition of UM that elevates cost and resource issues over clinical issues.

Management Tips

This standard is quite straightforward, and yet is often missed, at least on desktop review.  It is the classic example of URAC's “it is not enough that you do it right, you must have a policy and procedure that requires that you do it right” philosophy.

Very simply, submitting provider contracts that, in accord with the standard, do not include the two prohibited types of the language, is not enough.  You must also have a policy and procedure that prohibits the inclusion of such language in all provider contracts.  So, in your application, submit both a template agreement and the policy and procedure.

URAC Accreditation Tips

Both elements of this standard are mandatory.

For the desktop review, submit your applicable P&Ps (see Management Tips, above) and sample provider contracts.

The onsite review will involve an examination of between 15 and 30 provider contracts, as well as interviews of provider contracting management staff members.

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.

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

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

All three elements of this standard are mandatory.

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

The elements of these standards are either mandatory or weighted 4..

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

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 two elements of this standard are weighted 4.

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