The Basics

This standard requires that your organization implement a process to give consumers access to an independent review process that they can access after they have exhausted all the internal appeals mechanisms.  

"Independent review" means "process, independent of all affected parties, to determine if a health care service is medically necessary and medically appropriate, experimental/investigational or to address administrative/legal issues."  So, once a consumer has gone through all the appeal mechanisms that your organization offers (including those needed to comply with URAC standards HUM 30-36), if coverage is still denied, they can go to through this independent process.  Typically, this is through an "independent review organization" ("IRO") which, in most states, is either an organization that is hired by your organization to conduct such a review, or an agency or process provided by the government (either state or federal).  Make sure you know which is the case for your organization.  It may even be that your organization refers its commercial business consumers to a private IRO and its Medicaid, Medicare, or other government business consumers to a government-provided independent review process.

This standard imposes five basic requirements on the independent review process provided by your organization.  IROs must:

• use appropriate experts to make the determinations;
• have no direct financial interest in either your organization or the outcome of their decision;
• make non-urgent decisions within 30 days of the initiation of the independent review process by the consumer;
• make urgent decisions within 72 hours; and
• may not have been involved in the original decision that is under appeal.

Management Tips

This is an oft-regulated area, with both state laws and government purchasers of health plan services having independent review requirements.  Be sure your P&Ps cover all the possible independent review process that apply to your organization.  

At the very least, the independent review process must be available to consumers appealing decisions of medical necessity and denials based on the decision that the care is investigational or experimental.  

We recommend that you establish a separate tracking mechanism for cases that go through an independent review process.  In addition, if your organization operates in multiple jurisdictions and/or has government clients (e.g., Medicare or Medicaid), you should have a table available to all affected employees that outlines the various independent review requirements.

URAC Accreditation Tips

This standard hastwo mandatory elements and four elements weighted 4.

For the desktop review, submit your P&Ps outlining the independent review processes.  In addition, submit a sample template letter for adverse appeal determinations that describes the availability of the independent review process and the steps required to start such a process.  Finally, provide a report of all your independent review cases from the last year.

The onsite review will involve an examination of a sampling of case files showing how you've implemented the independent review process.  In addition, your medical director and senior utilization management staff will be interviewed by the URAC reviewer regarding the independent review process.