The Basics

What happens when one of your organization's consumers has to navigate a change of benefit plans, a change of benefits, or a change of care settings?  All of these fall into the category of "transitional situations", which is the subject of this standard.

The standard is an open-ended requirement that the organization have a process for managing such situations.  That process should include guidance on how to communicate with both the prescribing provider and the consumer in such situations, although it is in the organization's discretion as to how that communication takes place.  At a minimum, however, the process must involve a method to identify consumers who are faced with transitional situations, protocols for communications, and guidance on how to handle consumer and prescriber inquiries about transitions.

Management Tips

When a standard specifically mentions the word "process", there is increased pressure to make sure you have a policy and procedure to address the requirements of the standard.  Merely handling transitions correctly will not suffice; you must have a clear policy and procedure that establishes accountabilities and protocols for identifying consumers and communicating with them throughout the transition process.

URAC Accreditation Tips

The single element in the standard is weighted 3.

The documentation for desktop review should be a policy and procedure, described above, sample notification letters, and perhaps even a screenshot of electronic announcement of a changing your formulary.

The on-site review will involve an interview of customer service and clinical staff members, as well as one or more compliance officers.  In addition, the reviewer will examine transitional request records and the organization's responses to those requests.