The v. 5.1 upgrade to UM 34 is a partner to the revision to UM 33 (see blog on that standard here).  Like the UM 33 revision, this is billed as a "clarification of intent" standard.  Also like the UM 33 revision, it is a significant clarification.

The 5.0 version read:

Standard appeals are completed, and written notification of the appeal decision issued, within 30 calendar days of the receipt of the request for appeal. (Primary)

The question not answered by this standard was "to whom does the notification go?"  But then, one would have thought that UM 35 answered the question.  That standard reads, in relevant part:

For appeals determinations, the organization issues written notification of the adverse appeal decision to the patient and attending physician or other ordering provider or facility rendering service . . ..

But this deals only with affirmations of non-certifications -- what about the appeals that overturn the "non-certs"?  

URAC sorts it all out in the v. 5.1 UM 34:

Standard appeals are completed, and written notification of the appeal decision issued, within 30 calendar days of the receipt of the request for appeal to the patient and attending physician or other ordering provider or facility rendering service. (Primary)

In other words, the written notice of the appeal decision, no matter which way the decision goes, must be sent to both the patient and the provider.

The Basics

This standard requires that the organization notify everybody (consumer, attending physician, ordering provider) of its decision to grant a request for certification.  That notification must include tracking information (e.g., case number).  It can be oral, but there must be a mechanism to provide the notification in writing upon request.  It is particularly important that you document the notification, including the recipients and the date, in the case file.

Management Tips

The notification requirements of this standard must be documented in both a P&P that describes the process and in the case files showing the implementation of the P&P.

A particular curiosity is the use of the word "and" between the provider and the patient in this subsection. A literal reading of the standard would suggest that the organization must notify both. How many of us, though, ever receive direct notification from our insurers or UM companies of a certification decision? Darn few, I would suggest. The good news is that URAC has made it clear that it is acceptable to have the provider notify the patient. A word of caution -- your P&P on the subject should clearly place the obligation on the provider to let the patient know of the certification decision.

The "tracking number" in subsection (b) is a number that the consumer or the provider can use to track down the authorization, should they have to call the organization.

URAC Accreditation Tips

The standard is weighted 4.  The first element, carrying the URAC requirement of notification, is primary.  The other elements, requiring tracking information and a mechanism for providing the notice in writing, are secondary.

Documentation to be submitted to AccreditNet is straightforward -- a P&P and sample correspondence should suffice.

During the onsite review, the URAC reviewer, in her examination of clinical review files, look for documentation of this notification, either in the form of certification letters or notes in the file.

The Basics

The standard's purpose is to establish time frames for notification of the patient and provider in the event of expedited appeals.  There are two of them:

• 72 hours from the request to a verbal notification of the appeals decision
• 3 calendar days from the verbal notification to a written notification of the appeals decision

The 72-hour verbal notice need go only to the requesting party, whether it be the provider or the patient.  Only the written notification needs to go to both the consumer and the provider.  

Management Tips

Make sure your P&P on the topic is clear that the clock starts ticking on these time frames when the request to initiate the appeal is made.  that initiaion happens regardless of whether the request is in writing or via telephone.  Note, too, that the clock starts on written notification when the request lands in the mail room or receptionist's desk, not the UM department.

URAC Accreditation Tips

This standard is mandatory.

Again, the desktop submission is only the P&P and sample correspondence.  

The onsite review will focus on the case files of expedited appeals.

The Basics

Under this standard, if anybody (patient, physician, ordering provider) so requests, the organization must provide the clinical rational for its denial of the request for certification.  The clinical rationale clarifies the clinical reason for the non-cert decision.  It must relate specifically to the patient's condition and/or treatment plan.

It is not enough to simply refer generally to the clinical criteria.  Rather, the rationale must relate the patient's condition to the criteria, and provide enough information for the patient to pursue an appeal of the decision if he/she so desires.

Management Tips

You will recall that the notice of non-certification, which we discussed in an earlier page, requires that patients and providers be notified of their right to the clinical rationale.  So, integrate the P&P for that standard with the P&P for this one.  As that earlier page noted, it may be that the UM program will not have to have a separate process for providing clinical rationale if it does so in the non-certification letter. 

URAC Accreditation Tips

This standard is weighted 4, and its sole element is primary.

Documentation for AccreditNet is straightforward -- submit the P&P describing the process plus a copy of a template letter for providing the clinical rationale.  The onsite reviewer will interview staff members and look at case files to document implementation of the P&P.

This standard, while easy to comply with, is not a slam dunk.  It provides:
The organization:

(a) Requires utilization management staff to identify themselves by name, title, and organization name; and

(b) Upon request, verbally informs patients; facility personnel; the attending physician and other ordering providers; and health professionals of specific utilization management requirements and procedures.

It carries a weight of only 3, and neither of its subsections is primary.  So, it is surely true to say that you can miss this all together and still have a great shot at accreditation.  However, since it is our theory as URAC consultants that we should leave no points on the table, is worth just a little extra staff training time to sweep up these readily available points.

The most common mistake that we have found relating to this standard happens when utilization management staff members identify themselves only by name and organization, omitting the job title.  This, obviously, is both easy to detect and easy to fix.

Less common, but perhaps slightly more difficult to address is the requirement of subsection (b).  A good way to diagnose problems with the standard is periodically to pose such requests to the members of your utilization management staff.  The question might sound like this: “imagine that I am a patient, and I want to know what the procedures are to get my procedure approved, and I want you to tell me in writing.  What are you going to send to me?” 

Obviously, this presumes that you have something easy to send to providers and patients that summarizes utilization management procedures and requirements.  If these procedures are embedded in a larger document that you do not want to send, I recommend that you have a ready supply of copies of that section of the document available for your staff members to send out to requesting providers and consumers.

The Basics

This standard places strict limitations on what non-clinicians (i.e., the administrative employees) in the UM program may do.  The short version is that they should never be put in a situation of evaluating or assessing clinical information.  For the most part, they shouldn't even touch clinical data.  Tasks should be limited to collecting non-clinical information and responding to service requests that have nothing to do with clinical evaluations.  The only occasion in which non-clinicians should touch clinical data is if they are collecting it in a structured format (e.g., tightly supervised scripts or automated mechanisms for collecting clinical data.

This standard is the first of a trio of standards designed to set clear restrictions on the use of non-clinical personnel in the review process.  As the Program Guide notes, it applies to all review processes, regardless of the degree of automation, that do not involve clinical judgment and that do not result in non-certification determinations.

Management Tips

Managers will need to make sure that your P&P on this topic explicitly outlines the responsibilities of non-clinical review staff, their reporting relationships, and scope of work.  You should also make sure your non-clinical staff members' job descriptions are clear in communicating that they are not involved in clinical evaluations.

URAC Accreditation Tips

The standard is weighted “4”, and subsections (a) and (d) are primary elements.

Documentation for desktop review includes your P&Ps on the topics and sample job descriptions of your non-clinical staff members.  It also is a good idea to submit sample scripts or algorithms for non-clinical review.

The on-site review will focus on interviews, demonstrations of any automated systems, and a review of sample scripts or algorithms.  More importantly, the URAC reviewer will be examining case files or evidence that the P&P regarding non-clinical staff involvement is strictly followed.

Do not be misled by the fact that the standard is weighted “4”.  It is inextricably linked to UM 9, which is weighted “5” and is therefore a mandatory standard.  Problems with compliance with UM 7 likely will trigger noncompliance with UM 9, destroying any chance your organization has of attaining full accreditation.

The Basics

This standard applies to all three types of UM reviews (prospective, concurrent, and retrospective), and governs the way the UM organization seeks, accepts, and uses information relevant to those reviews.  The organization:

• Must consider information from all reliable sources, so long as the sources will help with the decision
• Should collect no more information than is necessary to make the decision, including not routinely requiring all medical records for a patient
• May ask for, but may not routinely require, numerical codes for diagnoses or procedures
• Must share the information it receives in-house, so that multiple members of the organization are not submitting duplicative requests to providers and patients for information

The standard can best be understood as providing protection for the patient and providers from abusive and/or unnecessary requests for information upon which to base a certification determination.  In a nutshell, it requires that the organization use “all reasonable sources of information to collect only the information required,” and to share that information within the organization “so as to avoid repeated requests for information from enrollees or providers.”

Management Tips

This is one of those policies in which it is best to take the hint in the Program Guide: “UM organizations may take language from the URAC standards and weave it into their policies and procedures, evaluating it to make sure that it reflects their current way of doing business.”  Make sure, however, that your P&P is clear that your reviewers should request additional medical records if and only to the extent necessary.

Design your P&P to make sure that your organization doesn't make requests for the same information multiple times.  This can happen if information is not shared or if people work in what management consultants call "silos", or parts of the company that do not have regular communication with other parts of the organization.

In our experience as URAC consultants, the most common required change in organization’s policies and procedures on the subject is the elimination of a routine requirement numerically coded diagnoses or procedures.    The standard is quite clear in stating that such a routine requirement is simply not allowed.

URAC Accreditation Tips

The standard carries a weight of 4, and two of its six elements are primary.

The only documents you'll need to submit for desktop review are all the relevant P&Ps.  The onsite review will focus on the UM case file review.  In addition, the reviewer might ask to see documentation of reimbursement to providers for making copies, in order to make sure this is being done according to your P&P.

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

The standard is weighted 4, and all the elements are primary.

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

The Basics

This standard governs communications with providers and patients.  The organization needs to be able to receive communications from those two groups both during the business day and after hours.  In addition, you need to be able to respond to provider and patient communications within one business day.  Finally, the standard requires that your communications to providers occur during "reasonable and normal business hours" unless you have an agreement with the provider to the contrary.

Note that this standard does not apply to requests for certification.  Those time frames are covered in other standards.  This is limited to other, more administrative inquires from providers and patients.

Management Tips

This standard is anomalous because it uses business days, not calendar days, as its metric. This makes sense, however, since it covers only administrative communications, not communications covered elsewhere in the standards (especially requests for review determinations), and because the standard emphasizes that communications should take place during reasonable and normal business hours.

The key here is to articulate clearly in your P&Ps all the various ways you receive administrative requests, what mechanisms are in place to receive them after hours, and that you’ll respond within one business day during business hours. 

You have some flexibility in defining whether you'll respond via telephone or other electronic methods.  Just make sure your P&P is clear on this point.

URAC Accreditation Tips

This standard is weighted 4.  The first element is primary, while the other two are secondary.

The documentation to be submitted for this standard at the AccreditNet phase is merely the applicable P&Ps.  During the onsite review, the reviewer not only will talk to your staff members about their understanding of the communications requirements, but also observe them in action at their desks.  

The applications we’ve seen more frequently leave out the “after hours” component of the P&Ps more than anything else, so don’t overlook it!