The Basics

This standard requires that your organization notify the consumer of the existence of a right to appeal a non-certification decision and instructions on how to pursue such an appeal.  In addition, it appears to require that you provide similar notification to the consumer regarding exceptions.  However, the earlier standard regarding the contents of the written notification of non-certification makes no mention of describing how to pursue an exception.  URAC offers no explanation for this apparent discrepancy, so, until it issues a clarifying interpretation, it is probably safe to assume that the written notification of non-certification, as required in DrUM 14, will suffice.

Management Tips

To be safe, it may behoove you to expand your appeals policy to include a provision for providing the consumer instructions on how to pursue an exception.  While you're at it, it probably makes sense to amend your template written notification of non-certification to include such instructions.

If you have notification of appeals instructions on your website, make sure they comply with this standard and the earlier standard on written notification of non-certification.  Further, it would be useful to develop scripts for the customer service representatives so that, when asked, they can provide accurate information on how to pursue an appeal and exception.

URAC Accreditation Tips

This is a mandatory standard.

For the desktop review, submit the applicable policies and procedures, a template written notification of non-certification, and, if applicable, a screen shot of any information you have on your website about how to pursue an exception and/or appeal.

During the on-site review, the reviewer will examine your complaint logs, your appeal request tracking system, and appeals files to assess compliance with this standard.