The Basics

This standard requires that any staff members conducting initial clinical review are health professionals and have an active relevant professional license.  What this means for most organizations is that the first evaluation of clinical evidence to determine whether a request for certification can be granted or referred to a physician for further review is done by a licensed nurse.  An LPN qualifies under this standard. 

Note that there is no requirement about same-state licensure here, so, if state law permits, an organization may have a nurse licensed in one state reviewing requests for certification from another state.  (Beware of that state law caveat -- if you violate state regulations here, you'll be tripping over the regulatory compliance standard, even if you comply with this one). 

Note, too, that you don't get off the hook by having an very highly qualified, but unlicensed, reviewer.  An example of this might be an unlicensed physician, who may not serve in this capacity under this standard.

Management Tips

The key here is to make sure the job descriptions of your clinical staff members who perform initial clinical review actually require an active relevant professional license.  It will not be enough that your staff members meet this requirement; rather, it is also required that your job descriptions and any applicable P&Ps actually require such licensure.

URAC Accreditation Tips

This is a mandatory standard, and both elements are primary.

Desktop-level documentation should be, at the least, the relevant job descriptions.  You may also submit P&Ps that contain the two requirements of this standard, as well.

During the onsite review, the reviewer will examine UM case file records to identify who is conducting the initial clinical review, then check to make sure that all such persons have active licenses.  Remember, you need to verify the licensure status through primary source verification.