The Basics

This standard establishes to be minimum requirements for the health professionals who conduct appeals from non-certification decisions.  At a minimum, such professionals must:

• be either a licensed physician, pharmacist, or other licensed health care professional;
• be board certified (if applicable);
• be in the same or similar specialty as typically manages the medical condition, procedures, or treatment under review;
• neither be the person who made the original decision not to grant certification nor a subordinate of that person.

Your organization may have its own panel of appeals reviewers, or it may refer all such appeals to an independent review organization ("IRO").  Naturally, the standard applies only for those appeals that your organization handles for its clients.  Many clients retain the rights to handle the appeals themselves, and therefore remove your organization's need to comply with the standard for those appeals.

Management Tips

Unfortunately, this standard is more confusing than it might initially appear.  The main confusion arises out the very real possibility that the appeal reviewer is a pharmacist, as permitted by subsection (a), and yet required to be in a "similar specialty that typically manages a medical condition, procedure, or treatment," as required by element (d).  URAC has a history of giving great deference to the treating physician about the specialty of the person conducting the appellate review.  Therefore, if your organization typically has pharmacists conducting the review on appeal, you also should be fully prepared to refer to the appeal to a physician specialist, should the prescriber request that such a professional review the appeal.  An even safer approach would be to refer all appeals to a URAC-accredited IRO.

URAC Accreditation Tips

All of the elements of this standard are mandatory except for the board certification requirement, which is weighted 3.

For the desktop review, you should submit not only the applicable policy and procedure, but also job description of a health professional that conducts appeals and a sample template of correspondence related to appeals (such as the denial of certification written notification).

During the on-site review, the URAC reviewer will select 30 appeals files from your appeals law.  He/she will examine those files for evidence that appropriately qualified healthcare professionals are performing the review on appeal.  You should also be prepared to present the full list of names and specialties of appeal reviewers, along with credentialing information about the licensure and board certification of each.