The Basics

This standard simply requires that the peer clinical reviewer be available to the attending or ordering providers for a conversation about the utilization management process.  This right for the treating provider(s) to a conversation applies to both prospective and concurrent reviews.  It means that either the reviewer himself/herself be available telephone or in person, or that a back-up peer reviewer be made available within one business day.  

The availability of the reviewer must be "timely", which means either before the review deterimination is made or right after it is made.  

Don't mix this up with the "appeal" of a review determination, covered by different standards.  This is simply a conversation between the ordering provider and the initial peer reviewer -- an appeal would involve (under URAC's rules and state and federal law) a different provider and an entirely different set of guidelines.

Your organization should have a P&P that covers this standard and the next one, also about a peer-to-peer conversation.  It is not enough, however, that your peer reviewer is available to talk with the ordering provider; your organization's P&P also provides for your organization to notify the ordering provider that he/she has this option.  So, make sure you can answer the question, "who tells the ordering provider that he/she has a right to a peer-to-peer conversation, and when does s/he tell him/her?"  It may be that this notification is in writing, or by telephone, or both.  

Management Tips

Your P&P must describe clearly the process by which you both offer the treating/attending provider this peer conversation and actually have that conversation.  The P&P should cover situations in which your peer clinical reviewer is not available for such a conversation.  Make sure the P&P articulates a clear distinction between this process and the appeals process.  URAC is quite clear that this conversation is intended to precede an appeal of a denial of a request for certification.

You also should standardize the method of notifying the provider of his/her right to this conversation, whether you convey this via letter, email, telephone, or other method.  So, develop templates and scripts to help your staff members deliver this notification consistently.  Finally, make sure your staff documents any oral transmission of the offer, and that your peer clinical reviewers document the conversation itself.

URAC Accreditation Tips

This standard is weighted 4.

For your application, submit not only the P&P describing this process, but also the job descriptions or contracts for those persons performing peer clinical review (you've submitted them already for some of the other standards).  In addition, if you provide the notification to the ordering provider by way of a letter, submit a template of that letter.

During the onsite review, the reviewer will look for written evidence that the ordering provider was offered the opportunity for a peer-to-peer conversation.  So, make sure you have a system for documenting when that notification is oral, as well as for keeping any written communication.