The Basics

This standard sets forth a group of requirements for your PBM's communications processes.

First, it requires that you have policies and procedures to address the timeliness of responses to communications that you receive by means other than telephone.

Second, if your PBM performs clinical triage, you must have a clinical staff person who responds to clinical communications from consumers by:

• directly answering the clinical communication; or
• receiving a direct transfer from a non-clinical member of your staff; or
• taking no more than 30 minutes to respond to clinical communications in the event of the clinical staff person is not immediately available.

Third, in the event a clinical communication is not answered directly by a staff person, your PBM has a process to instruct the consumer (either with a recording or a live person) to choose at least one of these options:

• hang up and dial 911 if it is an emergency; or
• remain on hold for the next available clinical staff person; or
• leave a message for the clinician.

All of these will need to be spelled out in a policy and procedure, so make sure that you are aware of which policy and procedure your organization is using to comply with the standard.

Management Tips

You will need to have two kinds of documentation for this standard: a comprehensive policy and procedure that contains all of the elements of this standard and documentation of the implementation of the standard.  Examples of implementation include:

• copies of automated operator or voice response unit scripts;
• a reporting mechanism so that you can summarize data related to telephone statistics.  

These reports also will be useful in connection with demonstrating compliance with the access and availability standard in the PHARM Core module.

URAC Accreditation Tips

The two elements addressing telephonic response are mandatory.  The element addressing communications other than by telephone is weighted 2.

For the desktop review you will need to submit a combination of the policy and procedure, telephone scripts, and reports of performance of the call center demonstrating assessment of consumer access and availability.

The on-site reviewer will examine clinical case records for evidence of compliance with the standard.  In addition, he/she will monitor call center staff to see if the standard and the organization's policies and procedures are being adhered to in the handling of consumer calls.  In addition, the reviewer likely will examine quality management committee minutes and reports to the QMC regarding how your organization monitors clinical staff response time frames.  In addition, the reviewer is likely to ask for QM audit reports.