The Basics

This standard sets forth the requirements for the situation in which you receive a request for certification, but determine that there is not enough information provided to make such a decision.

Check with your organization's P&P on this topic, because URAC has given your organization a lot of flexibility on how to handle such cases.  At a minimum, however, those P&Ps must:

• Establish clear and appropriate time frames for such things as how long you have to ask for more information, how long the patient/provider has to respond, and when you will issue an administrative denial for lack of information
• Establish a policy for what to do when the patient and/or provider do not provide the necessary information within the specified time frame
• Provide a process for issuing an administrative denial if, even after your request, you don't receive enough information to make a certification decision

It will be incumbent on you to record in the case file all your activities, whether by telephone, email, or letter.  The URAC reviewer will be checking to make sure you are complying with your company's P&P (particularly time frames), so recording the dates of your activities will be important.

Management Tips

Note that this standard specifically mentions P&Ps, so pay close attention to how you write yours.  URAC gives you flexibility on setting time frames, but you should note that the Department of Labor regulations may dictate those for you.  Check with legal counsel on this.  

Make sure your P&P is not so demanding as to make the submission of sufficient information onerous.  If the provider provides some clinical information and tells you that is all that is available, your staff should process it as a regular request for certification (prospective, concurrent, or retrospective).

URAC Accreditation Tips

All four elements of this standard are weighted 4.

The only documentation necessary for the desktop review is your P&P on lack of information.  The onsite review will focus on the examination of case files (to make sure you are complying with your own P&P) and interviewing UM staff members (to make sure they understand your P&P).