The Basics

This standard requires that your organization, to the extent that your contracts with clients give your organization this responsibility, implements written P&Ps to assure that your consumers have access to:

• covered services that are not available from the providers in your network and
• emergency care, whether within or outside the organization' service area.

The organization no doubt has a policy and procedure on how to handle such a situation; make sure that you are familiar with exactly how your organization has decided to handle these two situations.

Management Tips

Your policy and procedure on the two situations described in the standard must apply to any employee in your organization that might be called upon to explain to the consumer the policy.  So, in addition to network management staff, you likely need to make certain that your customer service representatives who deal with these issues are familiar with your policy.

URAC Accreditation Tips

The two elements of the standard are both mandatory.

For the desktop review, submit both your policies and procedures addressing these two issues and any consumer documents that you use to explain to consumers your policies.  This might be a consumer handbook or sample letters to consumers.  In addition, at this stage you should submit sample scripts for your customer service representatives.

During on-site review, the reviewer will interview your network management staff, and perhaps also your customer service representatives, to make sure that they understand how to handle inquiries regarding both issues.