The Basics

UM 1 requires that the organization's clinical review criteria/scripts meet certain conditions.  Appropriate provider/experts need to have been involved with their development or approval, as well as their annual review.  They need to be based on sound science.  Finally they need the approval of a medical/clinical director.

Management Tips

A standard covers both internally-developed clinical criteria and commercial criteria.  However, the key distinction is in the review and approval process described in subsections (c) and (d).  For internally developed clinical criteria, the process is quite clear: the organization and actively-practicing physicians must review the criteria which, in turn, also must be approved by the medical director or clinical director.

For commercial criteria, the standard is a bit different in application, if not in general requirement.  Most commercial vendors of criteria update those criteria annually.  This annual updating process generally takes care of the requirements of subsection (c).   Of course, the criteria still need to be approved by the medical director.  However, if the organization does not receive annual updates from the commercial vendor, it is still incumbent upon the organization to put the criteria through the annual review required by subsection (c), including a review by actively practicing physicians.

URAC Accreditation Tips

The standard is weighted "4", and all subsections are primary elements.

The documentation required to be submitted for desktop review is straightforward: a policy and procedure describing the development and approval of criteria along with sample pre-review scripts or clinical criteria.

The real test, however, will be during the on-site review.  It is during that stage of the accreditation process that the reviewer will be asking to see specific documentation of the review process for the criteria.  She'll confirm not only the approvals by the senior clinician, but also documentation of expert involvement in development and review of the criteria/scripts.  She'll also look at case records to insure that they are being used properly.

What will be important for companies undergoing the reaccreditation process to remember is that the documentation of the clinical criteria review process must show annual review and approval.  It will not suffice for a three-year accredited company to show merely that it looked at the criteria recently.  Rather, documentation only to demonstrate the annual review required by this standard.