The Basics

This standard requires that the organization notify everybody (consumer, attending physician, ordering provider) of its decision to grant a request for certification.  That notification must include tracking information (e.g., case number).  It can be oral, but there must be a mechanism to provide the notification in writing upon request.  It is particularly important that you document the notification, including the recipients and the date, in the case file.

Management Tips

The notification requirements of this standard must be documented in both a P&P that describes the process and in the case files showing the implementation of the P&P.

A particular curiosity is the use of the word "and" between the provider and the patient in this subsection. A literal reading of the standard would suggest that the organization must notify both. How many of us, though, ever receive direct notification from our insurers or UM companies of a certification decision? Darn few, I would suggest. The good news is that URAC has made it clear that it is acceptable to have the provider notify the patient. A word of caution -- your P&P on the subject should clearly place the obligation on the provider to let the patient know of the certification decision.

The "tracking number" in subsection (b) is a number that the consumer or the provider can use to track down the authorization, should they have to call the organization.

URAC Accreditation Tips

The standard is weighted 4.  The first element, carrying the URAC requirement of notification, is primary.  The other elements, requiring tracking information and a mechanism for providing the notice in writing, are secondary.

Documentation to be submitted to AccreditNet is straightforward -- a P&P and sample correspondence should suffice.

During the onsite review, the URAC reviewer, in her examination of clinical review files, look for documentation of this notification, either in the form of certification letters or notes in the file.