The Basics

Your organization's pharmacy contracts must contain certain provisions listed in this standard:

• list of the parties to the contract
• preconditions for the mission as a participating pharmacy (for example, licensure)
• the mutual obligations of the parties to the agreement
• events that would entitle your organization to modify or end the participation privileges of a participating pharmacy
• the term of the agreement and any procedures for terminating the agreement
• rules surrounding pharmacy audits
• any rules regarding at your organization's access to applicable consumer records
• a listing of services to be provided in any restrictions on the services
• claims submission requirements and limits on consumer billing
• fees and payment methodology
• dispute resolution
• a protection of the confidentiality of personal health information of consumers

Management Tips

For documentary obligations for the standard can be met in a variety of ways, but include for most organizations not only a template agreement that meets all of the requirements of the standard, but a policy and procedure or pharmacy provider manual that also addresses most if not all of the requirements of this standard.  We recommend that your pharmacy provider manual contain as many of these elements as makes sense (excluding, of course, provisions like listing of the parties).  Make sure that the policy and procedure and template contracts are in accord with each other.

URAC Accreditation Tips

Each of the elements of the standard is weighted 4.

Your contracting policy and procedure and template pharmacy agreements will be your minimum submission for desktop review.  We also recommend submitting a list of any major revisions to your contracts with in the last couple of years.

During the on-site review, your contracts will be examined for compliance with the standard.  If four or more contracts are found to have suffered from the same deficiency, the reviewer is likely to find a "pattern" of noncompliance with the element, resulting in a loss of points.