The Basics

This standard requires that your criteria for selecting providers to participate in your network address quality of care and service requirements.  In addition, you should have criteria that allow you to exclude otherwise eligible providers from your network should business reasons apply.

The quality requirements are relatively straightforward.  For quality of care, most URAC applicants submit their credentialing requirements, such as valid, unrestricted license in the applicable state, current DEA certificate (if applicable), appropriate education and training for specialty, board certification in specialty, proof of liability insurance or self insurance, good standing with Medicaid and Medicare, etc.  For quality of service, we usually see requirements regarding responsiveness of the provider’s office staff, cleanliness of the provider’s office, hours of operation, and the like.  

The "business reasons" element is a bit trickier for some.  As URAC's interpretive comments note:

NM 3(c) is intended to allow the organization flexibility in not accepting providers that otherwise meet the criteria for quality and service.  For example, if the organization already has enough qualified primary care providers, it might not accept another qualified primary care provider based on business needs.

Make sure your documentation gives you the flexibility to say "no" if your network is full in that specialty or some other business reason has you want to restrict a network (except, of course, if you operate in a state with an "Any Willing Provider" law).  

URAC Accreditation Tips

The quality of care and service elements of the standard are mandatory; the business needs element is weighted 4..

Your initial documentary submission should include the documents that establish these minimum requirements for inclusion in the provider network, whether they be P&Ps, a credentialing plan, or some other official organizational document.  

The onsite review will involve management interviews to assure an understanding of the organization's policies on all three elements.