The Basics

This standard adds three requirements for your organization's UM appeals process:

• The patient and/or provider(s) may submit additional information in their effort to overturn the original denial of certification
• Your organization must take all that information, plus all the information originally submitted, into account as it considers the appeal
• Your organization must go along with a decision by the appeal reviewer to overturn a previous denial of certification, although it does have the option to pay even if the reviewer upholds the denial

Management Tips

Make sure your P&P is clear on the point that these appeals standards refer only to appeals from denials of requests for certifications.  Administrative denials are not the subject of this or any of the UM appeals standards.

URAC Accreditation Tips

All three elements of this standard are primary.

As in most of the other appeals standards, you'll be fine submitting only the applicable P&P and template correspondence regarding appeals rights.

The onsite review will focus on a review of case files of appeals of denials of certification.