The Basics

This straightforward mandatory standard simply requires that all non-certifications be rendered by either a pharmacist or physician.  Naturally, this does not prohibit other staff members from issuing a denial on purely administrative grounds.  However, it is an absolute prohibition on clinical denials by anyone other than a pharmacist or physician.

Management Tips

In addition to taking sure you have a clear policy and procedure that embodies this critically important standard, it is also important that every member of the drug utilization management staff understand it.  In addition, because compliance with the standard will be assessed primarily through case file review, it is vital that documentation of who makes the non-certification decision be absolutely clear.

URAC Accreditation Tips

This is a mandatory standard.

Documentation for this standard is simple: combination of job descriptions of the prior authorization staff members and a policy and procedure making it clear that only physicians and pharmacists may issue clinical denials should suffice.

During the on-site review, the reviewer will interview the personnel who issue non-certifications.  In addition, the reviewer will request a log of non-certifications, from which he/she will select 30 files.  Those files will be examined to assure compliance with the standard.