The Basics

To protect against the possibility of inappropriate denials by the automated review system, this standard requires that the automated review process be overseen by one of four persons or bodies:

• a licensed health care professional with professional experience in providing patient care who holds a post secondary degree in healthcare;
• a senior employee or consultant who is clinically qualified form clinical triage and provide health education services;
• the P&T committee; or
• an appropriate committee composed of at least two experts (physicians, pharmacists, or other providers).

Check your organization's policies and procedures on how that oversight is exercised.  Your organization has a great deal of flexibility within the standard as to how it conducts oversight.

Management Tips

This standard grants a lot of flexibility around how you design the oversight of the automated review system.  It could include a transfer of proposed denials to a senior clinician, periodic review of inappropriate denials by the oversight committee, or a decision by a senior clinician to override the automated review process for specific situations.

URAC Accreditation Tips

This is a mandatory standard.

For desktop review, documentation should include the appropriate automated review policy and procedure, as well as any documentation as to how your organization tracks denials and appeals from automated review decisions.

During the on-site review, the reviewer will interview clinical staff involved in the oversight of the automated review system.  He/she also will examine selected automated review appeal files and minutes from any committee charged with the oversight of the automated review process.