The Basics

This standard requires that your organization implement mechanisms to make sure that your marketing activities do not misrepresent:

• information about benefit plans
• your organization's provider availability and accessibility (e.g., the contents of your provider directory, the extent of your service area)
• plan coverage (information about what conditions are covered)
• administrative requirements
• anything you require of consumers who are navigating your medical management systems

These communications mechanisms must include training of any employees and/or consultants (agents, brokers) who represent the organization's services to potential and actual clients and consumers.  

Management Tips

It is important that your marketing documentation addresses each of the above five components of this standard.  For example, in your training documentation showing that your staff and agents have been trained, make sure that you separate out the elements of the training into benefits, providers information, coverage, administrative requirements, and medical management.  

URAC Tips

Three of the elements are mandatory, and two are weighted 4.

For the desktop review, submit your P&Ps, training documentation (manuals, agendas, attendance logs, and 1 or 2 samples of marketing documentation.  Make sure you keep the number of documents to a maximum of 9.

It may be the case that one or more lines of business have no marketing associated with them (e.g., Medicaid in some states for some plans).  Explain this in the notes accompanying your marketing P&Ps in AccreditNet.

During the onsite review, the reviewer will interview marketing staff members about how the organization's P&Ps on this topic are implemented.  In addition, during the reviewer's visit with customer service representatives, he/she may ask the CSR to demonstrate that the CSR has access to accurate information about all the elements of this standard.