The Basics

This standard requires that your DM program use specified criteria, or rules, to identify who is eligible to participate in the program.  The rules must be specific for each condition in the program, and be applied in a consistent manner.  Those criteria must:

• Apply to all potential participants;
• Describe both inclusion and exclusion criteria for each condition;
• Specify the frequency with which they are applied;
• Be applied to data within a time frame that your documents specify; and
• Identify and define the data elements and sources your program uses to identify consumers with the clinical condition.

Management Tips

The key documents here likely are P&Ps or program descriptions.  Remember to address each clinical condition in your program.   The criteria may be specific to a particular client. 

URAC Accreditation Tips

All five elements of the standard are weighted 4.

For the desktop review, submit the applicable P&Ps and/or program descriptions.  In addition, you should submit sample documentation of any data runs used in implementing the condition-specific criteria.

The onsite reviewer will look for evidence of implementation of this standard during the review of consumer case files.  She also will discuss implementation of the program’s eligibility policies with the program’s senior management.