The Basics

This standard sets forth 14 minimal requirements for the organization's information analysis mechanisms.  Those mechanisms must be able to address:

• therapeutic appropriateness;
• overutilization and underutilization;
• generic drugs;
• the authorized exchange of therapeutic alternatives;
• duplication of prescription;
• drug-disease contraindications;
• interactions between drugs or between a drug and analogy;
• dosage;
• treatment duration;
• misuse or abuse of drugs;
• precautions concerning the use of a drug based on the patient's age;
• precautions concerning the use of a drug based on the patient's gender;
• pregnancy-related concerns; and
• limitations rooted in regulatory or benefit constraints.

These requirements typically are written into the organization's computer software, either in the claims the system or other clinical tools designed to alert the staff appropriately. 

Management Tips

It will not be enough to have well-design software to pass the elements of the standard.  Rather, the organization also has to have a comprehensive policy and procedure that requires that the software have all of these elements accounted for.  The policy and procedure should not only address the design of the software, but also the mechanisms for the intake of the necessary information and the implementation of appropriate interventions when the software generates alerts.

URAC Accreditation Tips

All of the elements of this standard are mandatory.

The documentation required for this standard is the applicable policy and procedure as well as a screenshot of the software used to handle the information required by this standard.

During the on-site review, the reviewer will observe the clinical review staff using the software, an interview staff members regarding the use.  In addition, the reviewer will examine utilization management review requests to see documentation of the use of clinical criteria and handling of those review requests.