For many of the URAC accreditation programs, an essential component of the onsite review is one or more file reviews.  For example, for Health Plan and Health Network, the reviewer will examine provider contracts to assess compliance with the applicable Network Management standards. Similarly, the medical management modules (UM, WCUM, CM, DM, DrUM, etc.) involve reviews of consumer case files to assess compliance with standards in each of those modules.

There are a few things to know about the file reviews:

• Files are selected in the morning of the review from a case log. Right after the opening remarks, the reviewer(s) will select files for review. They will do so from a log of the case files. Therefore, you'll need to be able to present a list to the reviewer(s) of all the cases in a particular category in the form of a case log. 
• Case logs should be separated by category. If there are several types of files to be reviewed during the onsite review, make sure you have a separate log for each type. So, if your organization seeks HUM accreditation, be sure your expedited reviews are separated from your standard reviews, and that your first-level reviews are in a separate log from your appeals. 
• Files will be selected from the full period for which you are being assessed. If your organization is seeking reaccreditation, you'll need to be able to provide logs all the way back to your date of accreditation. If you are a first-time applicant, files can be pulled all the way back to the day you hit "submit" on your document submission to AccreditNet.
• Files must be produced within 90 minutes (and we recommend quicker). Once the URAC reviewer hands you a list of files to be pulled, she will expect the files to be back to her within 90 minutes. We have found that, if you can get them there in 60 minutes, the reviewer will be even happier (which is a state of mind in which you want your reviewer). This is true even if you keep your records off-site. If you keep records off-site, you still need to be able to produce them for the reviewer within 90 minutes. We won't begin to list the ways you might end up doing it, but you should address this issue early in the process, as the logistical challenges may be substantial. The only exception to this rule is Health Plan/Network provider contracts. If you keep them off-site, you may ask the reviewer to preselect contracts for review before she shows up at your offices, giving you a few days' lead time to pull them. Do not expect this kind of leaway for UM, CM, DM, or other medical management patient case files. URAC's rule on this is very firm.

The Basics

This standard sets forth the general requirement that the organization's P&Ps address DrUM criteria for such things as: 

• optimal drug use,
• evaluation of the consumer clinical information provided with the authorization request, and 
• review timeliness.

The criteria for evaluating the data submitted by the consumer, prescribing provider, and/or pharmacy along with the request for authorization must:

• address discrepancies between optimal and actual use;
• coordinate intervention when it is appropriate to pursue treatment alternatives; and
• evaluation of program effectiveness.

It is particularly important to understand what URAC means by "Drug Utilization Management", or "DrUM as we'll call it throughout these pages.  It is your organization's evaluation of the "medical necessity, appropriateness, and efficiency of the use of health care services, procedures, products, and facilities under the provisions of the applicable health benefits plan; sometimes called 'drug review.'”  URAC distinguishes this from straight, non-clinical benefit determinations.  So, for example, a benefit exclusion for a particular drug, say, Rogaine, is not DrUM.  On the other hand, a process that looks at a covered drug and determines whether it is medically necessary and/or appropriate for the particular patient is the DrUM process.  

Management Tips

Make sure to draft clear P&Ps that outline: 

• the process of developing the criteria mentioned in this standard, 
• the process used by the DrUM staff members to apply the criteria,
• the timeframes for each component of the DrUM process, from start to finish, 
• safety protocols used in the DrUM program, including the tracking system for outbound communications for safety interventions, 
• a description of the DrUM case tracking mechanism(s), and
• approaches to evaluating the DrUM program for effectiveness.

Mere tracking is not the same as aggregating and evaluation, as is required for the evaluation of effectiveness of the DrUM program.  Therefore, make sure that your tracking mechanisms' data are aggregated and perhaps turned into reports that go to the quality management committee for evaluation.

URAC Accreditation Tips

Each of the six elements of this standard is mandatory.

For the desktop review, submit the applicable P&Ps, organization charts, and any evidence of program evaluation such as reports of such evaluations to the quality management committee.

The onsite review will involve an examination of your current applicable DrUM P&Ps, a demonstration that your staff members can access those P&Ps, interviews (at their desks) of DrUM staff members, and a review of any reports of program effectiveness, probably from minutes of the quality management committee. 

The Basics

This standard sets for the minimum requirements for your appeals records:

• Patient name
• Name of provider and/or facility rendering service
• Copies of all patient correspondence
• Copies of all provider/facility correspondence
• Actions taken and the dates they were taken, including decisions, correspondence, and resolution
• Minutes from any appeal proceedings
• The name and credentials of the appeals reviewer for each case

Management Tips

Note that this standard applies not only to the records themselves, but to the Appeals P&P.  In other words, your P&P needs to be explicit about your appeals record-keeping practices.  

URAC goves you flexibility about these records and their storage -- electronic and paper are both fine.  

URAC Accreditation Tips

All five elements of this standard are weighted 3.

The Appeals P&P and any logs containing the required information should be submitted for desktop review.

The onsite reviewer will look at your log and your case files to verify compliance with this standard.

The Basics

This standard sets for the minimum requirements for your appeals records:

• Patient name
• Name of provider and/or facility rendering service
• Copies of all patient correspondence
• Copies of all provider/facility correspondence
• Actions taken and the dates they were taken, including decisions, correspondence, and resolution
• Minutes from any appeal proceedings
• The name and credentials of the appeals reviewer for each case

Management Tips

Note that this standard applies not only to the records themselves, but to the Appeals P&P.  In other words, your P&P needs to be explicit about your appeals record-keeping practices.  

URAC goves you flexibility about these records and their storage -- electronic and paper are both fine.  

URAC Accreditation Tips

All five elements of this standard are weighted 3.

The Appeals P&P and any logs containing the required information should be submitted for desktop review.

The onsite reviewer will look at your log and your case files to verify compliance with this standard.

The Basics

This standard sets for the minimum requirements for your appeals records:

• Patient name
• Name of provider and/or facility rendering service
• Copies of all patient correspondence
• Copies of all provider/facility correspondence
• Actions taken and the dates they were taken, including decisions, correspondence, and resolution
• Minutes from any appeal proceedings
• The name and credentials of the appeals reviewer for each case

Management Tips

Note that this standard applies not only to the records themselves, but to the Appeals P&P.  In other words, your P&P needs to be explicit about your appeals record-keeping practices.  

URAC goves you flexibility about these records and their storage -- electronic and paper are both fine.  

URAC Accreditation Tips

This standard is weighted 4, and is comprised of both primary and secondary elements.

The Appeals P&P and any logs containing the required information should be submitted for desktop review.

The onsite reviewer will look at your log and your case files to verify compliance with this standard.

The Basics

This standard prescribes the minimum requirements for the written notice of an adverse appeal decision (one upholding the initial denial of the request for certification):

• It must be sent to the patient and ordering provider or facility
• It must state the principal reasons for the decision
• It must state that your organization will provide the clinical rationale underlying decision in response to a written request
• It must describe any additional appeal mechanisms and how to access them, if they exist

Management Tips

See the earlier standard on the notice of denial of certification for a full discussion of the principal reason and clinical rationale issue.  The same issues that apply to that letter apply to this letter.  Make sure the case files contain the written notice and that it is dated.

URAC Accreditation Tips

The three elements of the standard are weighted 4.

Again, the appeals P&P and applicable templates are what you submit to AccreditNet.

The onsite reviewer will focus on appeals case files and staff interviews.

The Basics

This standard prescribes the minimum requirements for the written notice of an adverse appeal decision (one upholding the initial denial of the request for certification):

• It must be sent to the patient and ordering provider or facility
• It must state the principal reasons for the decision
• It must state that your organization will provide the clinical rationale underlying decision in response to a written request
• It must describe any additional appeal mechanisms and how to access them, if they exist

Management Tips

See the earlier standard on the notice of denial of certification for a full discussion of the principal reason and clinical rationale issue.  The same issues that apply to that letter apply to this letter.  Make sure the case files contain the written notice and that it is dated.

URAC Accreditation Tips

The three elements of the standard are weighted 4.

Again, the appeals P&P and applicable templates are what you submit to AccreditNet.

The onsite reviewer will focus on appeals case files and staff interviews.

The Basics

This standard prescribes the minimum requirements for the written notice of an adverse appeal decision (one upholding the initial denial of the request for certification):

• It must be sent to the patient and ordering provider or facility
• It must state the principal reasons for the decision
• It must state that your organization will provide the clinical rationale underlying decision in response to a written request
• It must describe any additional appeal mechanisms and how to access them, if they exist

Management Tips

See the earlier standard on the notice of denial of certification for a full discussion of the principal reason and clinical rationale issue.  The same issues that apply to that letter apply to this letter.  Make sure the case files contain the written notice and that it is dated.

URAC Accreditation Tips

The standard is weighted 4, and the elements are primary except for the offer of clinical rationale.

Again, the appeals P&P and applicable templates are what you submit to AccreditNet.

The onsite reviewer will focus on appeals case files and staff interviews.

The Basics

This standard requires that, in the case of a standard appeal, you send written notification of the decision within 30 calendar days of the receipt of the request for appeal.  That notice needs to go to both the patient and the ordering provider or treating facility.

Management Tips

As with expedited appeals, the clock starts ticking when the request for appeal first hits your organization, not your department.  That means any part of your organization, including a call to the customer service department, or a letter to a mail room.  All delays in getting that request into the right hands in the UM department count against the time frame embodied in this standard.  Date-stamping, therefore, becomes very important.

Make sure your appeals tracking mechanism can distinguish between expedited and standard appeals.

URAC Accreditation Tips

This standard has a weight of 4.

Submit the Appeals P&P and template appeals correspondence at the desktop review stage.

The onsite reviewer will look at your appeal tracking log, select a certain number of files, and review them to make sure you comply with the time frame required by this standard.

The Basics

This standard requires that, in the case of a standard appeal, you send written notification of the decision within 30 calendar days of the receipt of the request for appeal.  That notice needs to go to both the patient and the ordering provider or treating facility.

Management Tips

As with expedited appeals, the clock starts ticking when the request for appeal first hits your organization, not your department.  That means any part of your organization, including a call to the customer service department, or a letter to a mail room.  All delays in getting that request into the right hands in the UM department count against the time frame embodied in this standard.  Date-stamping, therefore, becomes very important.

Make sure your appeals tracking mechanism can distinguish between expedited and standard appeals.

URAC Accreditation Tips

This standard has a weight of 4.

Submit the Appeals P&P and template appeals correspondence at the desktop review stage.

The onsite reviewer will look at your appeal tracking log, select a certain number of files, and review them to make sure you comply with the time frame required by this standard.