The Basics

This standard governs time frames for retrospective review determinations.  

Let's start with the definition of retrospective review: UM determinations made after the services (in-patient or out-patient) have been delivered to the patient.

Obviously, there's no "urgent care" determination issue here, as there was for precertification.  So, the basic rule is that you have 30 calendar days after you receive the request for certification.  Like the precertification rules, you can extend this time for reasons beyond your control, including insufficient information to make the determination.  Also like precertification, you must notify the patient before the expiration of the initial time frame (in this case, 30 days).  If you need more information, you must specifically describe the information you need.  The patient must have up to 45 days to respond to your request for more information.

Management Tips

Make sure the P&P describes this whole process clearly.  Also make sure that you have standardized, via template letters, the mechanisms for extending the time frame and for requesting more information.  The onsite review will focus on a review of case files, so make sure all the steps in the retrospective review process are clearly documented.

URAC Accreditation Tips

This standard has a weight of 3, and all the elements are secondary.

The applicable P&P and your template notice of extension are all that you need to submit at the desktop review stage.

During the onsite review, the URAC reviewer will assess your compliance with the standard through a combination of case file reviews and interviews with staff members.