The Basics

This standard's purpose is to establish time frames for notification of the patient and provider in the event of expedited appeals.  There are two of them:

• 72 hours from the request to a verbal notification of the appeals decision
• 3 calendar days from the verbal notification to a written notification of the appeals decision

The 72-hour verbal notice need go only to the requesting party, whether it be the prescriber or the patient.  Only the written notification needs to go to both the consumer and the provider.  

URAC defines expedited appeal as any appeal in a case involving any situation in which applying normal time standards would threaten the life or health of the consumer or the ability of the consumer to regain maximum function or would subject the patience to severe pain that can't be adequately managed without the requested care.

Management Tips

Make sure your P&P on the topic is clear that the clock starts ticking on these time frames when the request to initiate the appeal is made.  that initiaion happens regardless of whether the request is in writing or via telephone.  Note, too, that the clock starts on written notification when the request lands in the mail room or receptionist's desk, not the UM department.

It will be particularly important that your appeal record system can capture:

• the date and time the organization received a request for appeal (date- and time-stamping will be helpful);
• the date and time of the initial notification; and
• the date and time of the written notification.

URAC Accreditation Tips

This standard is mandatory.

Again, the desktop submission is only the P&P and sample correspondence.  

The onsite review will focus on the case files of expedited appeals.