The Basics

This standard sets forth time frames for the conduct of concurrent review.  Concurrent review is UM conducted either in the midst of treatment (in-patient or out-patient) and/or while he/she is in the hospital.  The basic rule is that, if the UM organization intends to terminate or reduce a previously approved course of treatment or hospitalization that is underway, it should give the patient enough time to request a review of the decision and get a decision before the organization implements the decision.

That is straightforward enough.  However, the challenge comes in when the patient asks for an extension of that course of treatment or hospital stay.  In this regard, the standard itself is not written particularly well, as it leaves out certain scenarios.  A clarifying comment that URAC posted in March 2009 is a better source for understanding the time frames than the standard itself.  The time frames depend on two things -- whether the request is for urgent care, and whether it is received at least 24 hours before the certification expires.  Here's how it breaks down:

• If the request for extension is received more than 24 hours before expiration:
• If the case involves urgent care,  notification must be within 24 hours of receipt of request
• If the case involves non-urgent care, notification must be within 72 hours of receipt of request
• If the request for extension is received less than 24 hours before expiration, regardless of the urgency of the care, notification must be within 72 hours of receipt of the request

Management Tips

Again, the primary management role is to make sure the P&P is clearly written and the staff well-trained on the time frames.  

URAC Accreditation Tips

Each element of this standard carries a weight of 4.

The required documentation is relatively straightforward: a policy and procedure describing your process, and a sample template of a written notice to the patient.  

The on-site review, while straightforward, is substantially more rigorous: the reviewer will go through case files to make sure that you are meeting all of these timelines.

The Basics

This standard sets forth time frames for the conduct of concurrent review.  Concurrent review is UM conducted either in the midst of treatment (in-patient or out-patient) and/or while he/she is in the hospital.  The basic rule is that, if the UM organization intends to terminate or reduce a previously approved course of treatment or hospitalization that is underway, it should give the patient enough time to request a review of the decision and get a decision before the organization implements the decision.

That is straightforward enough.  However, the challenge comes in when the patient asks for an extension of that course of treatment or hospital stay.  In this regard, the standard itself is not written particularly well, as it leaves out certain scenarios.  A clarifying comment that URAC posted in March 2009 is a better source for understanding the time frames than the standard itself.  The time frames depend on two things -- whether the request is for urgent care, and whether it is received at least 24 hours before the certification expires.  Here's how it breaks down:

• If the request for extension is received more than 24 hours before expiration:
  • If the case involves urgent care,  notification must be within 24 hours of receipt of request
  • If the case involves non-urgent care, notification must be within 72 hours of receipt of request
• If the request for extension is received less than 24 hours before expiration, regardless of the urgency of the care, notification must be within 72 hours of receipt of the request

Management Tips

Again, the primary management role is to make sure the P&P is clearly written and the staff well-trained on the time frames.  

URAC Accreditation Tips

All the elements of the standard are weighted 4.

The required documentation is relatively straightforward: a policy and procedure describing your process, and a sample template of a written notice to the patient.  The on-site review, while straightforward, is substantially more rigorous: the reviewer will go through case files to make sure that you are meeting all of these timelines.

The Basics

This standard governs time frames for retrospective review determinations.  

Let's start with the definition of retrospective review: UM determinations made after the services (in-patient or out-patient) have been delivered to the patient.

Obviously, there's no "urgent care" determination issue here, as there was for precertification.  So, the basic rule is that you have 30 calendar days after you receive the request for certification.  Like the precertification rules, you can extend this time for reasons beyond your control, including insufficient information to make the determination.  Also like precertification, you must notify the patient before the expiration of the initial time frame (in this case, 30 days).  If you need more information, you must specifically describe the information you need.  The patient must have up to 45 days to respond to your request for more information.

Management Tips

Make sure the P&P describes this whole process clearly.  Also make sure that you have standardized, via template letters, the mechanisms for extending the time frame and for requesting more information.  The onsite review will focus on a review of case files, so make sure all the steps in the retrospective review process are clearly documented.

URAC Accreditation Tips

The element containing the 30 day deadline is weighted 3; the elements dealing with your mechanism for extending that time are weighted 4 each.

The applicable P&P and your template notice of extension are all that you need to submit at the desktop review stage.

During the onsite review, the URAC reviewer will assess your compliance with the standard through a combination of case file reviews and interviews with staff members.

The Basics

This standard governs time frames for retrospective review determinations.  

Let's start with the definition of retrospective review: UM determinations made after the services (in-patient or out-patient) have been delivered to the patient.

Obviously, there's no "urgent care" determination issue here, as there was for precertification.  So, the basic rule is that you have 30 calendar days after you receive the request for certification.  Like the precertification rules, you can extend this time for reasons beyond your control, including insufficient information to make the determination.  Also like precertification, you must notify the patient before the expiration of the initial time frame (in this case, 30 days).  If you need more information, you must specifically describe the information you need.  The patient must have up to 45 days to respond to your request for more information.

Management Tips

Make sure the P&P describes this whole process clearly.  Also make sure that you have standardized, via template letters, the mechanisms for extending the time frame and for requesting more information.  The onsite review will focus on a review of case files, so make sure all the steps in the retrospective review process are clearly documented.

URAC Accreditation Tips

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

The applicable P&P and your template notice of extension are all that you need to submit at the desktop review stage.

During the onsite review, the URAC reviewer will assess your compliance with the standard through a combination of case file reviews and interviews with staff members.

The Basics

This standard establishes the time frames for conducting prospective review.

First, a definition of "prospective review":  UM that your organization conducts before a patient’s admission, stay, or other service or course of treatment.  Your organization might call it something different, like “prior authorization.”  It can relate to the review of in-patient or out-patient services.

Now, the time frames:  

• The first thing to know is that you've got to make a determination as soon as possible.  That's not very specific, though so next,
• Ask the question, is the request urgent?  If so, make the determination in no more than 72 hours from the request.
• If it's not urgent, make the determination in no more than 15 calendar days.
• What if it's not urgent, and for reasons not in your control, you cannot make the determination?  Let the patient know you won't be able to meet the first 15 day deadline before that deadline expires, and tell him/her when you do think you'll be able to make the determination.  That gives you an extra 15 days.
• What if you need more information from the patient?  Let the patient know specifically what information you need (be sure to do this before the expiration of the above time frames).  You must give the patient at least 45 days to respond to this request for information.  Once you do this, the time frames are suspended -- the clock stops -- while you wait for the patient to respond.  Make sure you document the reasons for the extension and the dates the extension started and stopped.  
• What does "urgent" mean in this case, such that you get only 72 hours rather than 15 days to make a determination:  First, if the patient's doctor thinks it's urgent, it's urgent.  Second, if your organization thinks that applying the 15-day time frame "could seriously jeopardize the life or health of the consumer or the ability of the consumer to regain maximum function," it's urgent.

Management Tips

It is important for management,in its P&Ps on the subject, to spell out in specific detail who does what, when?  At what time do claims of urgency get referred to your medical director, if at all?  

Also, remember that "receiving" the request for certification happens the moment the request hits your organization, not when it gets to the UM department.  So, make sure the mechanisms for getting those requests into the right hands promptly are functioning.

In addition, "issue a determination" doesn't merely mean deciding whether to approve or disapprove a request.  Rather it means communicating that decision.  There's another URAC standard that governs how you do this and to whom you issue that determination. 

Make sure you standardize the means by which you (1) notify the patient and physician you intend to extend the time to issue a determination and (2) request more information to make your decision.

URAC Accreditation Tips

This standard is weighted 4.  The main elements are primary, while the elements concerning how to handle an extension of time are secondary.

For the desktop review stage, submit both your applicable P&Ps and your template letters that extend the time and/or ask for more information.

During the onsite review, the URAC reviewer will examine randomly selected UM case files to make sure you are meeting the deadlines not only for the determination, but for communications with the patient and physician.  It is vital, therefore, that the files be well-organized and that all the events described in this standard are documented.  

The reviewer also will interview various members of the UM staff to make sure they understand these time frames, especially around the issue of urgent care.

The Basics

This standard establishes the time frames for conducting prospective review.

First, a definition of "prospective review":  UM that your organization conducts before a patient’s admission, stay, or other service or course of treatment.  Your organization might call it something different, like “prior authorization.”  It can relate to the review of in-patient or out-patient services.

Now, the time frames:  

• The first thing to know is that you've got to make a determination as soon as possible.  That's not very specific, though so next,
• Ask the question, is the request urgent?  If so, make the determination in no more than 72 hours from the request.
• If it's not urgent, make the determination in no more than 15 calendar days.
• What if it's not urgent, and for reasons not in your control, you cannot make the determination?  Let the patient know you won't be able to meet the first 15 day deadline before that deadline expires, and tell him/her when you do think you'll be able to make the determination.  That gives you an extra 15 days.
• What if you need more information from the patient?  Let the patient know specifically what information you need (be sure to do this before the expiration of the above time frames).  You must give the patient at least 45 days to respond to this request for information.  Once you do this, the time frames are suspended -- the clock stops -- while you wait for the patient to respond.  Make sure you document the reasons for the extension and the dates the extension started and stopped.  
• What does "urgent" mean in this case, such that you get only 72 hours rather than 15 days to make a determination:  First, if the patient's doctor thinks it's urgent, it's urgent.  Second, if your organization thinks that applying the 15-day time frame "could seriously jeopardize the life or health of the consumer or the ability of the consumer to regain maximum function," it's urgent.

Management Tips

It is important for management,in its P&Ps on the subject, to spell out in specific detail who does what, when?  At what time do claims of urgency get referred to your medical director, if at all?  

Also, remember that "receiving" the request for certification happens the moment the request hits your organization, not when it gets to the UM department.  So, make sure the mechanisms for getting those requests into the right hands promptly are functioning.

In addition, "issue a determination" doesn't merely mean deciding whether to approve or disapprove a request.  Rather it means communicating that decision.  There's another URAC standard that governs how you do this and to whom you issue that determination. 

Make sure you standardize the means by which you (1) notify the patient and physician you intend to extend the time to issue a determination and (2) request more information to make your decision.

URAC Accreditation Tips

All five of the elements of this standard have a weight of 4.

For the desktop review stage, submit both your applicable P&Ps and your template letters that extend the time and/or ask for more information.

During the onsite review, the URAC reviewer will examine randomly selected UM case files to make sure you are meeting the deadlines not only for the determination, but for communications with the patient and physician.  It is vital, therefore, that the files be well-organized and that all the events described in this standard are documented.  

The reviewer also will interview various members of the UM staff to make sure they understand these time frames, especially around the issue of urgent care.

The Basics

This standard establishes the time frames for conducting prospective review.

First, a definition of "prospective review":  UM that your organization conducts before a patient’s admission, stay, or other service or course of treatment.  Your organization might call it something different, like “prior authorization.”  It can relate to the review of in-patient or out-patient services.

Now, the time frames:  

• The first thing to know is that you've got to make a determination as soon as possible.  That's not very specific, though so next,
• Ask the question, is the request urgent?  If so, make the determination in no more than 72 hours from the request.
• If it's not urgent, make the determination in no more than 15 calendar days.
• What if it's not urgent, and for reasons not in you control, you cannot make the determination?  Let the patient know you won't be able to meet the first 15 day deadline before that deadline expires, and tell him/her when you do think you'll be able to make the determination.  That gives you an extra 15 days.
• What if you need more information from the patient?  Let the patient know specifically what information you need (be sure to do this before the expiration of the above time frames).  You must give the patient at least 45 days to respond to this request for information.  Once you do this, the time frames are suspended -- the clock stops -- while you wait for the patient to respond.  Make sure you document the reasons for the extension and the dates the extension started and stopped.  
• What does "urgent" mean in this case, such that you get only 72 hours rather than 15 days to make a determination?  First, if the patient's doctor thinks it's urgent, it's urgent.  Second, if your organization thinks that applying the 15-day time frame "could seriously jeopardize the life or health of the consumer or the ability of the consumer to regain maximum function," it's urgent.

Management Tips

It is important for management,in its P&Ps on the subject, to spell out in specific detail who does what, when?  At what time do claims of urgency get referred to your medical director, if at all?  

Also, remember that "receiving" the request for certification happens the moment the request hits your organization, not when it gets to the UM department.  So, make sure the mechanisms for getting those requests into the right hands promptly are functioning.

In addition, "issue a determination" doesn't merely mean deciding whether to approve or disapprove a request.  Rather it means communicating that decision.  There's another URAC standard that governs how you do this and to whom you issue that determination. 

Make sure you standardize the means by which you (1) notify the patient and physician you intend to extend the time to issue a determination and (2) request more information to make your decision.

URAC Accreditation Tips

All five of the elements of this standard have a weight of 4.

For the desktop review stage, submit both your applicable P&Ps and your template letters that extend the time and/or ask for more information.

During the onsite review, the URAC reviewer will examine randomly selected UM case files to make sure you are meeting the deadlines not only for the determination, but for communications with the patient and physician.  It is vital, therefore, that the files be well-organized and that all the events described in this standard are documented.  

The reviewer also will interview various members of the UM staff to make sure they understand these time frames, especially around the issue of urgent care.