The Basics

This standard prohibits an organization from reversing a decision to certify unless the organization receives new, relevant information that it did not have when it first certified coverage.  For example, if the PBM later finds out that it should not have certified because it was a duplicate claim, but did not have the information that it was duplicate when it first approved it, it should have policies and procedures that provides guidance on how it will go about reversing the decision.

It may be that the organization never reverses decisions to certify regardless of new information.  Check your policy and procedure to see if this is the case for your organization.

Management Tips

First, it must be said that your organization does not have to have a provision under which it reverses certifications.  If you like, you can prohibit certification reversals altogether.  However, if it is your organization's policy to reverse certification decisions, you'll need a policy and procedure that explains under what circumstances you will do that. In that case, your policy and procedure must state that you will do so only with newly-acquired information.

It also makes sense to draft a template letter for such circumstances.  This will help assure that you implement your policy and procedure in a uniform and consistent way.

URAC Accreditation Tips

The standard has a weight of 4.

For desktop review, and you should submit both the applicable policy and procedure and any templates correspondence you have developed to implement the policy and procedure.

During the on-site review, the reviewer will ask staff members about your policy of reversing certification decisions.  He/she is also likely to look for examples of certification reversals among the denial files that she selects for review.