The Basics

This standard sets forth what is required in your notification of your organization's decision to deny a request for certification.  This is a very important standard that is frequently missed, probably because it involves making some judgment calls about clarity of communication -- never an easy thing.  Nevertheless, it is vital to know how to do this standard.

The notice needs to go to the patient and at least one of the involved providers (including facility)

There are four required components of the notification letter:

• Principal reason
• A statement that your organization will provide a more detailed explanation (called the "clinical rationale") in writing upon request
• Instructions for appealing your decision not to certify
• Instructions for requesting the clinical rationale

The toughest part for more organizations is making sure the principal reason gives enough information.  It doesn't need to be extremely detailed, but it does need to be specific to the patient and his/her condition.  What is quite certain is that it is not sufficient merely to say "treatment not medically necessary" or "doesn't meet guidelines for certification."  It has to provide the patient and/or the provider(s) enough information on which to base an appeal.  

The clinical rationale is a much more detailed description of the reason, and might even involve a citation to the clinical standard involved in making the decision.

Management Tips

This one simply takes practice and experience on the part of the clinical peer reviewers issuing the denials.  It is also critical that the peer reviewers communicate clearly to the persons responsible for sending out the notification of denial of certification.

You can take care of three of the four requirements of this standard by providing the clinical rationale, rather than the principal reason, in the initial notice of noncertification.  If you do that, you naturally do not have to offer to provide the clinical rationale in writing or provide instructions on obtaining the clinical rationale, since you've already provided it.  Many organizations balk at providing such detail in the initial communication of denial, and some experts have noted that there are some regulatory agency requirements about keeping your explanation simple enough to be understood by a layperson that make it difficult for some organizations to take this approach. 

Make sure your template letter of notification of noncertification fully complies with this standard and is uniformly used by your staff members.  Also, be sure your P&P, and not just your template letter, compies with all the elements of this standard.

URAC Accreditation Tips

The elements requiring that you provide instructions on how to appeal and request clinical rationale are mandatory, while the other elements are weighted 4.

For the desktop review, submit the P&P covering this procedure and any template letters of noncertification.  The onsite review of your UM case files will be the primary activity of the URAC reviewer for this standard, making documentation of the timeliness and completeness of your notices of noncertification critical.