The Basics

This standard is the logical successor to the standards prohibiting denials by persons conducting either of the first two levels of review.  Since neither the initial administrative reviewer nor the initial clinical reviewer (UM nurse) can issue a clinical denial, this standard makes clear what is required if neither of these two approve a request:  put the request through a "peer clinical review". 

This standard and those that follow describe in detail what is required of the peer clinical review.  Sometimes called a "second level review," this part of the UM process must be handled by appropriate health professionals (as defined in subsequent standards). 

Management Tips

The central management responsibility here is to make sure that the applicable P&P clearly describes what happens if neither the administrative staff nor the nurse reviewer can issue a certification.  Furthermore, the job descriptions of the peer clinical reviewer(s) (typically the medical directors) must be consistent with that P&P and with this standard in describing his/her role in reviewing cases that cannot be certified in the first two levels of review.

URAC Accreditation Tips

This standard is mandatory.

Evidence supporting this standard is a combination of P&Ps describing the process of referring all clinical requests for certification that cannot be approved by administrators or nurses to the appropriate reviewers, as well as the job descriptions of the nurses and the peer reviewer (usually a medical director). 

Note this important requirement -- if you are approving a portion of the request, but not another portion of the request, it still needs to be referred upstream for peer clinical review.  In other words, a partial approval doesn't get you off the hook.

During the onsite review, the reviewer will be testing the training of the administrative and nursing staff to make sure this requirement is very clear to all staff members.  In addition, all the UM case files need to show that this process is handled properly in all cases.  This is a mandatory standard, so this component of the training is critical.