The Basics

This standard sets forth minimum requirements for the persons who conduct prospective review for the drug utilization management program.  Such a person can be one of two types of individuals:

• a licensed "health professional" with formal training in healthcare, experience in patient care, and a post-secondary degree in healthcare; or
• a pharmacy technician, trained to follow established criteria, who is licensed, if required by state law.

URAC requires that a pharmacy technician be "adequately trained to prepare and dispense pharmaceuticals and related products under direct supervision of a licensed pharmacist."  The training requirements can be met by showing either substantial training or extensive experience in a pharmacy.

It is particularly important that, if your organization uses pharmacy technicians for prospective review, they have access to a supervising pharmacist in the performance of their review duties.  In addition, pharmacy technicians must work entirely within the confines of algorithms that guide their decisions.  This means that, if the review is non-automated, the pharmacy technician cannot issue a denial of a clinical request for certification.

Your organization undoubtedly has a policy and procedure on this topic which may limit reviewer qualifications to one of these two options, so be sure you are familiar with your organization's policy.

Management Tips

While the requirements for prospective reviewers could be expressed only in the job descriptions, it is better practice to put such requirements into a relevant policy and procedure, too.  In addition, check with the organization's compliance department to make sure that the organization is taking into account all relevant regulatory requirements.  This is particularly important for organizations that operate in more than one state, as state regulations will vary on this point.

Make sure the job titles match up.  If your policy and procedure names one position as being qualified to perform prospective review, and you submit a job description for a position with a different title, you will end up confusing the reviewer.

URAC Accreditation Tips

All elements of the standard are mandatory.

For the initial submission of documents, the organization should submit job descriptions and/or a policy and procedure describing the minimum requirements set forth in this standard.  In addition, if state law or regulation governs the qualifications of the prospective reviewer, a sample of compliance documentation for such a regulation should be submitted.  Quality audits of prospective review staff and the organization's training plan for such their also will strengthen the submission.

During the on-site review, the reviewer will select the personnel files of the pharmacy technicians and other prospective reviewers.  The reviewer will select all of the personnel files if there were 30 or fewer; only 30 files will be selected if there are more than 30 personnel performing this function.  The reviewer will examine the personnel files to check issues such as credentialing, job descriptions, performance evaluations, training, and the verification of credentials.

In addition, the reviewer will interview prior authorization staff at their workstations.  It is particularly important that the reviewer be able to see quite clearly that any pharmacy technicians are using automated systems to conduct prospective review.