The Basics

This standard requires that your organization make available to consumers a rather extensive and specific list of items of information about your organization and its services:

• a description of the mechanisms by which your organization provides information for consumers for whom English is a second language or who have special needs, such as cognitive or physical impairments;
• a list of network providers;
• general descriptions of your compensation arrangements for participating providers;
• any tools that your organization makes available to consumers to help them in managing their own care;
• statistics about consumer satisfaction with your organization's services;
• administrative requirements;
• requirements regarding medical management (UM, CM, DM);
• health benefits;
• any financial responsibilities that your health plan imposes on consumers, such as deductibles, co-pays, co-insurance, etc.;
• any responsibilities that consumers bear for health benefits decision-making;
• any criteria for benefits that her condition-specific; and
• information about coordination of benefits.

Your organization no doubt has detailed policies and procedures addressing all of these points.  Make sure that you are familiar with those policies and procedures, and not just this standard's requirement.

Management Tips

Notes that you don't have to post all of this information in public places.  For example, you may choose to provide the provider compensation arrangements and consumer satisfaction statistics only upon request.  However, if you take that option, you must make sure that your customer service representatives and any other members of the staff who might be recipients of such a consumer request are fully trained on how to respond to those requests.  Furthermore, the provider compensation information described in this standard does not have to address specific compensation amounts; rather, it may provide a general description (e.g., capitation, fee-for-service).

URAC Accreditation Tips

All of the elements of the standard are weighted 4.

For the desktop review, submit written policies, consumer materials like a member handbook or a summary benefit plans, a portion of the provider directory, a screenshot from your consumer portion of your organization's website, evidence of training in the standards, and the results of consumer satisfaction surveys.  This is a lot, so be strategic so that you keep your documents and to submit to nine or fewer.

The on-site review will involve a thorough documentation review of consumer education materials and the organization's website.  In addition, the interviews will be conducted of senior management, marketing personnel, and customer service managers to assess understanding of all elements of your applicable policies and procedures.  In addition, the reviewer is likely to call your customer service representatives to see if they know how to respond to requests for information covered by the standard.