The Basics

This standard requires that the written notification of your standard appeal the decision be sent within 30 calendar days of your organization's receipt of the request for an appeal.  That receipt of the request for appeal is when the organization's mailroom first receives the request, not necessarily when the drug utilization management department receives it.  That notice needs to go to both the patient and the ordering provider or treating facility.

Management Tips

As with expedited appeals, the clock starts ticking when the request for appeal first hits your organization, not your department.  That means any part of your organization, including a call to the customer service department, or a letter to a mail room.  All delays in getting that request into the right hands in the DrUM department count against the time frame embodied in this standard.  Date-stamping, therefore, becomes very important.

Make sure your appeals tracking mechanism can distinguish between expedited and standard appeals.

URAC Accreditation Tips

This standard is mandatory.

Submit the appeals P&P and template appeals correspondence at the desktop review stage.

The onsite reviewer will look at your appeal tracking log, select a certain number of files, and review them to make sure you comply with the time frame required by this standard.