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 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 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

In this very important standard, URAC sets forth the minimum requirements for the clinician who handles an appeal of a denial of certification.  That person must:

• Be a "clinical peer" of the ordering provider.  Generally, this means that they are in the same licensure category as the ordering provider, and also need to be in the same or similar specialty as usually handles the condition that is the subject of the review.  
• Hold an active, unrestricted clinical license
• Be board certified
• Did not make the original denial
• Is not a subordinate of the person who made the original denial

Management Tips

It is very important that your P&P on appeals contain all of these requirements.  A very common mistake is to assume that your medical director(s) can handle most appeals.  This is simply not true, as URAC's FAQ on this topic makes crystal clear.  

It is important to note that this standard gives the ordering provider a trump card: if he/she wants the denial reviewed by a someone who shares their specialty, URAC wants you to do that, regardless of whether you think your selected reviewer is an expert in the field in question.

Several senior reviewers have put it this way -- "if your grandmother received a diagnosis from the ordering provider and you wanted a second opinion, would you go to someone with the specialty of the appeal reviewer for that opinion?" 

Another thing to watch out for is making sure an associate medical director does not handle an appeal of a denial by his/her boss.  

Make sure your P&P addresses the issue of who selects the appeal reviewer and what criteria they use for that selection.

Some organizations contract with panels of specialists or independent review organizations to handle their appeals.  In such cases, get an attestation each year from the vendor that all the providers have unrestricted licenses and are board certified.  

URAC Accreditation Tips

All the elements of this standard are mandatory except for the board certification requirement, which is weighted 3.

The AccreditNet submission should include the applicable P&P and templates of appeals-related correspondence.

In addition to a review of case files, the qualifications of peer reviewers will need to be available to the reviewer.

The Basics

This standard simply notes that state and/or federal regulations are likely to bear on the details of your appeals process, and requires that you coordinate your process with the applicable regulations.  These regulations may vary from jurisdiction to jurisdiction, so you'll need to watch for such variations in the way you handle appeals.

Management Tips

Take the pressure off your staff members by incorporating the regulatory requirements into your P&Ps.  If you have multiple regulators, you may need a reasonably sophisticated system to handle this in a way that makes it easy for your staffers to comply with the applicable laws in all cases.

URAC Accreditation Tips

The sole element of this standard is weighted 4.

As with the other appeals standards, submit your appeals P&Ps and template correspondence dealing with appeals.

The onsite review will bore in on the case files that have been appealed.

The Basics

This is the first of a series of standards that require the establishment and maintenance of a system of appeals of denials of certification requests.  This introductory standard sets forth a few general requirements for your UM appeals system and leaves the detailed requirements for that system to the subsequent standards.

This standard's general requirements are:

• The appeals system must address both urgent and non-urgent situations
• The appeals P&Ps must describe the appeals rights of the patient and any involved providers, including facilities
• The appeals P&Ps must describe the time frames for each component of the appeals process
• The appeals P&Ps must be available to any requesting patient or provider

Management Tips

We cannot stress enough the importance of having a P&P to cover appeals and to have a system for making it available.  Here's a good way to analyze your readiness for this standard:

Are your policies and procedures describing your non-certification appeals process available upon request to any patient, provider, or facility rendering service?

If you answer "yes" to this question, you're only partly on your way to meeting the requirements of this standard. One more question to go:

Does your P&P say that it's available to any consumer, provider, or facility?

If you say "no" to this question, it's time to revise your policy.

The standard requires that you have a "formal process" for appeals of non-cert decisions.  The process must be based in a P&P that (and the standard is quite explicit about this) any patient, provider, or facility involved in the patient's care may obtain upon request. 

Remember, in the world of URAC (or any other accreditation program), if it isn't documented, it isn't happening. So, it is not merely enough that you P&P is available, but it must say that it's available. And, you must submit this documentation with your application in order to avoid getting a comment from your reviewer asking for more documentation.

One other thing -- make sure you have an effective tracking system that allows you to retrieve UM denials that have been appealed, and to distinguish those cases in which the denial is upheld from those in which the denial was overturned.

URAC Accreditation Tips

All the elements are of this standard are mandatory.

For the desktop review phase, submit both your UM appeals P&Ps and a template for any correspondence relating to appeals.  

The onsite review will focus on the case file review and staff interviews.

The Basics

This standard sets forth the requirements for the situation in which you receive a request for certification, but determine that there is not enough information provided to make such a decision.

Check with your organization's P&P on this topic, because URAC has given your organization a lot of flexibility on how to handle such cases.  At a minimum, however, those P&Ps must:

• Establish clear and appropriate time frames for such things as how long you have to ask for more information, how long the patient/provider has to respond, and when you will issue an administrative denial for lack of information
• Establish a policy for what to do when the patient and/or provider do not provide the necessary information within the specified time frame
• Provide a process for issuing an administrative denial if, even after your request, you don't receive enough information to make a certification decision

It will be incumbent on you to record in the case file all your activities, whether by telephone, email, or letter.  The URAC reviewer will be checking to make sure you are complying with your company's P&P (particularly time frames), so recording the dates of your activities will be important.

Management Tips

Note that this standard specifically mentions P&Ps, so pay close attention to how you write yours.  URAC gives you flexibility on setting time frames, but you should note that the Department of Labor regulations may dictate those for you.  Check with legal counsel on this.  

Make sure your P&P is not so demanding as to make the submission of sufficient information onerous.  If the provider provides some clinical information and tells you that is all that is available, your staff should process it as a regular request for certification (prospective, concurrent, or retrospective).

URAC Accreditation Tips

All four elements of this standard are weighted 4.

The only documentation necessary for the desktop review is your P&P on lack of information.  The onsite review will focus on the examination of case files (to make sure you are complying with your own P&P) and interviewing UM staff members (to make sure they understand your P&P).

The Basics

This standard is limited to retrospective review.  In making the certification decision, the organization may only use the information that was available at the time the services were rendered to the patient.  In other words, there can be no "Monday morning quarterbacking," in which you use information acquired more recently than the rendering of the service to determine whether it was medically necessary.  

Management Tips

This is designed to protect providers from the unfair situation of being denied payment because the decisions they made in good faith given the information they had turned out to be incorrect, at least when viewed with the 20-20 vision of hindsight.  The same P&P you use for the previous standard is an excellent place for this language, as well.  Because it is a bit counterintuitive for some people, it is probably worth emphasizing this requirement in staff training.  

URAC Accreditation Tips

The standard has a weight of 4.

The P&P on this topic will be the only required documentation.  This is likely to come up in the onsite review only on review of case files and in interviews of peer reviewers and the UM staff.

The Basics

This standard applies only to prospective and concurrent reviews.  It requires that the UM organization base its review determination only on the information available at the time of the review.  While that may not make much sense out of context (how would you make the decision not based on the information available at the time of the review?), it makes more sense when you compare it to the next standard, which has a different rule for the information used for retrospective reviews.  Read together, the two standards make more sense.

Management Tips

This standard should be taken care of simply by a line or two in the P&Ps dealing with prospective and concurrent reviews.  Of course, it will make things easier if you also have a good method of tracking what information was used in the review and when it was available to you.  Scanning the documents with date-stamping will go a long way toward fulfilling that documentary requirement.  

URAC Accreditation Tips

This standard carries a weight of 4, and its sole element is primary.

For the desktop review, the P&P with the requisite language is all you will need to submit.

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
• 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 elements of this standard range in value from 2 to 4.

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.