The Basics

This standard requires that your organization providing 24/7 means of access for your consumers and they're treating providers in the event of urgent healthcare issues.  That access needs to be via a toll-free telephone line.  Your organization may address this issue in part by providing for the participating primary care physicians to serve as the organizational representative when your offices are closed.  If your organization does delegate responsibility to non-employees, those representatives must have authority to act as a representative of the organization. Whether that is the approach your organization takes or not, you should be familiar with the policy, and know that the essential point here is that consumers and providers be able to find somebody who can talk on behalf of your organization at all hours.

Management Tips

Make sure your communications plan is explicit on how it handles after hours calls.  Also make sure that your provider contracts support any delegation of after-hours called responsibility.  Your providers must have the authority to bind your organization if they are acting on behalf of your organization under this standard.  Make sure that if a provider does act on your behalf as a delegate, you don't deny the benefit.  An example of this might be if such a provider refers consumer to seek emergency care at a particular facility.  You may not go back later and deny that care.

It is permissible to play a recording after hours to direct consumers to the appropriate health service.

URAC Accreditation Tips

This standard is weighted 4.

For the desktop review, submit your communications plan.

During the on-site review, the reviewer will interview managers in your organization of irresponsibility of implementing this dimension of the communications plan.  In addition, the reviewer is likely to call as a "secret shopper" to be sure that there is 24/7 coverage.