The Basics

This standard establishes requirements for the organization's information-gathering activities in connection with drug utilization management.  First, it requires that the organization accept information in the context of an evidence-based process.  Second, it limits the information that is allowed to be collected to that which is relevant to the certification of the prescription.  Finally, it prohibits the organization from asking for more of the medical record than is necessary to review the request for certification.  As is apparent, the purpose of this standard is to provide reasonable protection to the consumer and the prescriber from the risk of unreasonable requests for information.

Management Tips

Two things are required for this standard: a policy and procedure which incorporates the substantive limitations of the standard, and any forms of that you use for receiving information in connection with prior authorization requests.

URAC Accreditation Tips

The elements of this standard are weighted between 2 and 4.

Documentation at the desktop review level should be the policy and procedure and template prior authorization forms.

During the on-site review, the reviewer will examine case files, with a particular eye toward the use of prior authorization request forms, to determine compliance with the standard.