The Basics

This standard adds four requirements for your organization's DrUM appeals process:

• The patient and/or provider(s) may submit additional information in their effort to overturn the original denial of certification
• Your organization must take all that information, plus all the information originally submitted, into account as it considers the appeal
• The appeal must be reviewed by a licensed health professional (physician or otherwise) who is in the sort of specialty as typically manages the medical condition, procedures, or treatment under review
• Your organization must go along with a decision by the appeal reviewer to overturn a previous denial of certification, although it does have the option to pay even if the reviewer upholds the denial

Management Tips

Make sure your P&P is clear on the point that these appeals standards refer only to appeals from denials of requests for certifications.  Administrative denials are not the subject of this or any of the UM appeals standards.

Some organizations contract with an IRO to perform the review function.  Contracting with a URAC-accredited IRO will save a substantial amount of headaches related to delegation oversight.

Read carefully the next page, about DrUM 23, for more information on the qualifications of the appeals reviewer.

URAC Accreditation Tips

All four elements of this standard are mandatory.

As in most of the other appeals standards, you'll be fine submitting only the applicable P&P and template correspondence regarding appeals rights.

The onsite review will focus on a review of case files of appeals of denials of certification.