The Basics

This standard establishes the time frames for conducting prospective review.

First, a definition of "prospective review":  UM that your organization conducts before a patient’s admission, stay, or other service or course of treatment.  Your organization might call it something different, like “prior authorization.”  It can relate to the review of in-patient or out-patient services.

Now, the time frames:  

• The first thing to know is that you've got to make a determination as soon as possible.  That's not very specific, though so next,
• Ask the question, is the request urgent?  If so, make the determination in no more than 72 hours from the request.
• If it's not urgent, make the determination in no more than 15 calendar days.
• What if it's not urgent, and for reasons not in your control, you cannot make the determination?  Let the patient know you won't be able to meet the first 15 day deadline before that deadline expires, and tell him/her when you do think you'll be able to make the determination.  That gives you an extra 15 days.
• What if you need more information from the patient?  Let the patient know specifically what information you need (be sure to do this before the expiration of the above time frames).  You must give the patient at least 45 days to respond to this request for information.  Once you do this, the time frames are suspended -- the clock stops -- while you wait for the patient to respond.  Make sure you document the reasons for the extension and the dates the extension started and stopped.  
• What does "urgent" mean in this case, such that you get only 72 hours rather than 15 days to make a determination:  First, if the patient's doctor thinks it's urgent, it's urgent.  Second, if your organization thinks that applying the 15-day time frame "could seriously jeopardize the life or health of the consumer or the ability of the consumer to regain maximum function," it's urgent.

Management Tips

It is important for management,in its P&Ps on the subject, to spell out in specific detail who does what, when?  At what time do claims of urgency get referred to your medical director, if at all?  

Also, remember that "receiving" the request for certification happens the moment the request hits your organization, not when it gets to the UM department.  So, make sure the mechanisms for getting those requests into the right hands promptly are functioning.

In addition, "issue a determination" doesn't merely mean deciding whether to approve or disapprove a request.  Rather it means communicating that decision.  There's another URAC standard that governs how you do this and to whom you issue that determination. 

Make sure you standardize the means by which you (1) notify the patient and physician you intend to extend the time to issue a determination and (2) request more information to make your decision.

URAC Accreditation Tips

This standard is weighted 4.  The main elements are primary, while the elements concerning how to handle an extension of time are secondary.

For the desktop review stage, submit both your applicable P&Ps and your template letters that extend the time and/or ask for more information.

During the onsite review, the URAC reviewer will examine randomly selected UM case files to make sure you are meeting the deadlines not only for the determination, but for communications with the patient and physician.  It is vital, therefore, that the files be well-organized and that all the events described in this standard are documented.  

The reviewer also will interview various members of the UM staff to make sure they understand these time frames, especially around the issue of urgent care.