The Basics

This standard is at the core of URAC's UM standards -- no nurses issue clinical denials.  

Period.

This goes back to the very beginning of URAC itself -- the most essential element of the UM standards is that only doctors say a clinical "no" to a request for certification.  There are no exceptions.  The only way that non-physicians can deny a request for certification is if the benefit itself is not covered under any circumstances.  If there is even an iota of evaluation of clinical information needed to say "no", that decision must happen later in the process, when a physician reviews the file.

So, while UM nurses can say "yes", they must refer all denials to the doctor(s).

Management Tips

The P&P must clearly express the prohibition embodied in this standard.  Furthermore, staff training should emphasize this essential principle of UM.

URAC Accreditation Tips

This standard is mandatory.

For the purposes of the initial application, you prove that this is the organization's policy by submitting the P&P that prohibits nurses from denying requests for certification on clinical grounds.  Make sure this is implemented utterly and completely, as the onsite review not only will include interviews of the nurses, but also a close examination of UM case files.