The CMS standard provides:

The MAO makes a good faith effort to conduct an initial health assessment of all new members within 90 days of the effective date of enrollment.

The implementing URAC standard is MAP-NM 18.

The Basics

This Medicare Advantage-specific standard imposes very detailed requirements on your organization regarding continuity of care and integration of services.  Specifically, the standard requires:

• Policies and procedures describing how your organization coordinates health care services.
• A mechanism to offer each consumer (and to provide to each requesting consumer) a source of primary health care.
• Mechanisms for coordinating services with community and social service agencies, such as nursing home and community-based services.
• Procedures that make sure that both your organization and the providers in your network have the necessary information to sure patients with effective in continuous care and a review of quality.  Specifically, this means
  • Any "best-effort" try at conducting an initial assessment of each new consumer's health-care needs within the first 90 days after the consumer enrolls.
  • Effective recordkeeping throughout the organization and provider network that complies with broadly-accepted professional standards; and
  • Mechanisms to assure confidential exchange of information among the various components of your provider network.
• Policies and procedures ensuring that your members are informed of follow-up requirements for specific healthcare needs, as well as training and self-care.
• Mechanisms to address obstacles to compliance by the consumer with prescribed programs, treatments, or regimens.

Management Tips

Naturally, implementation of the standard will require a robust combination of detailed policies and procedures and comprehensive staff training that spans provider network, clinical, and consumer relations staff members.

URAC Accreditation Tips

The desktop review submission should include applicable policies and procedures, sample records of completed health assessments (don't forget to "blind" to them), documentation of unsuccessful efforts to conduct initial health assessments, and a sample of the assessment questionnaire.  In addition, any sample telephone scripts that apply to the standard would be wise submissions.

The on-site review will involve an interview of staff members from the member services, disease management, case management, and/or utilization management staffs.  That interview well dig deeply into the conduct of the initial health risk assessments to determine familiarity by members of those staffs with your organization's procedures.  Questions will include:

• Is there a health assessment conducted upon enrollment within 90 days? If so can you show me some completed surveys?
• What then is done with the information?
• Do you contact the enrollee for DM or CM services?

The on-site document review will include a review of sample health risk assessments and the documentation of the referral process.