The Basics

This standard requires that those who conduct "peer clinical review" be a licensed doctor (either M.D. or D.O.) or in the came licensing category as the provider who ordered the procedure.  In other words, a licensed chiropractor could be the reviewer if the ordering provider also were a chiropractor.

In addition, the medical/clinical director must determine the peer reviewer to be qualified to render an opinion on the particular condition, procedures, and treatment that are the subject of the utilization review process.  

It's useful to think of a license as an M.D. or a D.O. as a "trump card" for either the ordering provider or the peer reviewer.  On the one hand, a licensed M.D./D.O. can review care ordered by any type of provider, even if not from the same license category.  On the other hand, if the ordering provider is an M.D./D.O., the reviewer must be one, also.  Psychologists and chiropractors may be reviewed by M.D./D.O.s, but not the other way around.

Management Tips

Of course, your applicable P&P needs to explicitly contain all the requirements of this standard.  If your organization uses contracted peer reviewers, make sure their contracts contain these requirements, too.  I also will be important to make sure the reviewer(s), whether employed or contracted, are trained in the applicable URAC standards and in your organization's P&Ps on peer clinical review.

URAC Accreditation Tips

All elements of this standard are mandatory.

Documentation for this standard is straightforward:  

• AccreditNet phase:  Job descriptions or contracts for peer clinical reviewers;
• Onsite Review phase: record of licensure (make sure it is primary-source verified!).