The Basics

This standard sets forth time frames for the conduct of concurrent review.  Concurrent review is UM conducted either in the midst of treatment (in-patient or out-patient) and/or while he/she is in the hospital.  The basic rule is that, if the UM organization intends to terminate or reduce a previously approved course of treatment or hospitalization that is underway, it should give the patient enough time to request a review of the decision and get a decision before the organization implements the decision.

That is straightforward enough.  However, the challenge comes in when the patient asks for an extension of that course of treatment or hospital stay.  In this regard, the standard itself is not written particularly well, as it leaves out certain scenarios.  A clarifying comment that URAC posted in March 2009 is a better source for understanding the time frames than the standard itself.  The time frames depend on two things -- whether the request is for urgent care, and whether it is received at least 24 hours before the certification expires.  Here's how it breaks down:

• If the request for extension is received more than 24 hours before expiration:
  • If the case involves urgent care,  notification must be within 24 hours of receipt of request
  • If the case involves non-urgent care, notification must be within 72 hours of receipt of request
• If the request for extension is received less than 24 hours before expiration, regardless of the urgency of the care, notification must be within 72 hours of receipt of the request

Management Tips

Again, the primary management role is to make sure the P&P is clearly written and the staff well-trained on the time frames.  

URAC Accreditation Tips

All the elements of the standard are weighted 4.

The required documentation is relatively straightforward: a policy and procedure describing your process, and a sample template of a written notice to the patient.  The on-site review, while straightforward, is substantially more rigorous: the reviewer will go through case files to make sure that you are meeting all of these timelines.