The Basics

The standard requires that your organization establish criteria for the selection of its independent reviewers.  In addition, it requires a credentials verification program for all such reviewers, as well as re-verification no less frequently than every three years.  The minimum requirements for the credentialing program are:

• verifying current licensure, current board certification, disciplinary and sanctions history, and professional experience; and
• actual or potential conflicts of interest.

Certainly, your organization may have more rigorous requirements than these minimums established by URAC; check the applicable P&P to make sure you are up-to-date on all the criteria.  

Management Tips

It is important to URAC that your credentialing system be strong enough to assure that a reviewer has current licensure and certification and no conflict of interest every time he/she receives a case file from you.  There are several suggested mechanisms you should consider including in your P&P:

• require your peer reviewers to notify you immediately if there are any changes to licenses or certifications;
• direct research of state licensing boards, NPDP, and OIG to find sanctions or disciplinary actions;
• an attestation by the peer reviewer for each case.

URAC Accreditation Tips

All of the individual elements of the standard are mandatory.

For the desktop review, you should submit a combination of the policy and procedure(s), a screenshot of your online credentialing database, if you use one, and any templates or forms that you might use, such as a conflict of interest questionnaire or attestation for the reviewer.

The on-site review will involve an examination of at least 30 randomly selected reviewer credentialing files.  100% of these files only to be in good order to pass the standard.  In addition, the members of your staff who verify credentials will be interviewed by the reviewer.  Finally, it is entirely possible that the reviewer will call at least two members of your reviewer panel.  You will be able to set up those reviews in advance.