The Basics

Pharm Core 22 requires that your organization implement a mechanism to inform both consumers and your clients of consumer rights and responsibilities.  Specifically, that mechanism needs to address at least advising them on how to obtain services and how to submit a complaint or appeal.

First, let's distinguish consumers and clients.  URAC defines "consumers" as follows: "An individual person who is the direct or indirect recipient of the services of the organization.  Depending on the context, consumers may be identified by different names, such as “member,” enrollee,” “beneficiary,” “patient,” “injured worker,” “claimant,” etc."  URAC defines "client" as "A business or individual that purchases services from the organization."  

It is entirely possible that the PBM not only does not handle communications with consumers at all, but also provides no consumer information to the client.  It's quite clear that in such cases, the standard does not apply.  In such cases, the organization mostly for consumer inquiries back to the client.

Management Tips

What managers need to understand about this standard is that your policies and procedures must describe the mechanism for providing information to consumers and clients about your organization's services and the complaint and appeal process.  It will not be sufficient to demonstrate to your act would provide consumers and clients this information.  You will need to have a policy and procedure that describes how you should do it.  In addition, you should have template letters of "bills of rights" to provide consumers.

URAC Accreditation Tips

Both elements of this standard have a weight of 4.

For the desktop review, your documentation should include not only your policy and procedure, but also documentation showing how you implement that policy and procedure, such as a Consumer's Bill of Rights, a portion of your member handbook, or a template of a consumer letter that describes consumer rights.

During the on-site review, compliance with this standard will be assessed primarily through interviews with both management and staff members charged with providing consumers with this information.  It will therefore be very important that preparation for the on-site review includes letting customer service representatives know that there are likely to be asked about the requirements of the standard when the reviewer tours the customer service department.