The Basics

In this very important standard, URAC sets forth the minimum requirements for the clinician who handles an appeal of a denial of certification.  That person must:

• Be a "clinical peer" of the ordering provider.  Generally, this means that they are in the same licensure category as the ordering provider, and also need to be in the same or similar specialty as usually handles the condition that is the subject of the review.  
• Hold an active, unrestricted clinical license
• Be board certified
• Did not make the original denial
• Is not a subordinate of the person who made the original denial

Management Tips

It is very important that your P&P on appeals contain all of these requirements.  A very common mistake is to assume that your medical director(s) can handle most appeals.  This is simply not true, as URAC's FAQ on this topic makes crystal clear.  

It is important to note that this standard gives the ordering provider a trump card: if he/she wants the denial reviewed by a someone who shares their specialty, URAC wants you to do that, regardless of whether you think your selected reviewer is an expert in the field in question.

Several senior reviewers have put it this way -- "if your grandmother received a diagnosis from the ordering provider and you wanted a second opinion, would you go to someone with the specialty of the appeal reviewer for that opinion?" 

Another thing to watch out for is making sure an associate medical director does not handle an appeal of a denial by his/her boss.  

Make sure your P&P addresses the issue of who selects the appeal reviewer and what criteria they use for that selection.

Some organizations contract with panels of specialists or independent review organizations to handle their appeals.  In such cases, get an attestation each year from the vendor that all the providers have unrestricted licenses and are board certified.  

URAC Accreditation Tips

All the elements of this standard are mandatory except for the board certification requirement, which is weighted 3.

The AccreditNet submission should include the applicable P&P and templates of appeals-related correspondence.

In addition to a review of case files, the qualifications of peer reviewers will need to be available to the reviewer.