The Basics

This standard requires your organization to establish a pharmacy dispute resolution process to address situations where your organization makes a decision, that the pharmacy contests, involving its

• status within the network; or
• competency or conduct; or
• distribution channel contractual issues.

The exact mechanism is largely up to your organization to establish, so long as it stays within any external requirements that may be imposed by contract or regulation.

Management Tips

We recommend that dispute resolution be clearly spelled out in the pharmacy provider manual.  An alternative location for that description could be in policies and procedures, but the reviewer is likely to favor a document, like the provider manual, that is shared with the pharmacies.  In addition, you'll want to make sure that there is nothing in your contract with pharmacies that is inconsistent with the dispute resolution mechanism description.  Make sure that whatever mechanism you come up with is fair on its face.  Giving a participating pharmacy industry record resolution mechanism that seems to have a predetermined outcome will not pass muster.

URAC Accreditation Tips

Each of the three elements of the standard carries the weight of 4.

Your initial documentary submission should include the pharmacy provider manual or other policy and procedure that describes the dispute resolution process, as well as any written agreements that refer to the process.  In addition, if you handle pharmacy disputes through a committee mechanism, documentation about the committee's involvement in the process should be submitted, as well.

During the on-site review, the reviewer will ask for a list of complaints or grievances made by participating pharmacies, as well as a list of pharmacy disputes.  From those lists, the reviewer will select a sample of pharmacy dispute files and examine them more closely to make sure that you are complying with your own policies and procedures.  In addition, your network management staff will need to know how the dispute resolution process works.