The Basics

In the event your organization makes a decision to deny a request for certification before the peer-to-peer conversation has occurred, the organization must, under this standard, make a post-decision conversation available to the ordering provider.  That conversation should be with either the person who makes the denial decision during peer clinical review or another, back-up clinical peer, if the original peer is not available.  That conversation should be available within one business day of the decision to deny.

In addition, if the conversation does occur, and the denial still stands, the organization needs to document that it has told the ordering provider of the appellate process that is available to the provider.

As is the case with the pre-denial peer-to-peer conversation, the organization must document not only the conversation, but the mechanism by which the provider is notified of his/her right to the conversation.  That notification may be done by writing or telephone or in the provider contract, but whichever means is chosen, it must be documented.

Management Tips

Make sure that your organization's P&P on this topic does not get this confused with the appellate process.  On the contrary, this conversation is a distinct part of the UM process that precedes the appeal.  

It will be important to standardize the method(s) by which your staff members record the offer of the conversation and your peer reviewers record the having of the conversation.  

URAC Accreditation Tips

The standard is weighted 4, with two primary and two secondary elements.

As one might expect, the documentation you need to submit to URAC via AccreditNet is a combination of the P&P describing the process, job descriptions that address the peer-to-peer conversation, and template documentation of the means to notify the provider of the right to this conversation.  During the onsite review, staff members will be questioned by the reviewer on their understanding of this process.  Furthermore, the reviewer will examine UM case files to see that the offer of the conversation has been documented in a consistent way.