The Basics

This standard applies to all three types of UM reviews (prospective, concurrent, and retrospective), and governs the way the UM organization seeks, accepts, and uses information relevant to those reviews.  The organization:

• Must consider information from all reliable sources, so long as the sources will help with the decision
• Should collect no more information than is necessary to make the decision, including not routinely requiring all medical records for a patient
• May ask for, but may not routinely require, numerical codes for diagnoses or procedures
• Must share the information it receives in-house, so that multiple members of the organization are not submitting duplicative requests to providers and patients for information

The standard can best be understood as providing protection for the patient and providers from abusive and/or unnecessary requests for information upon which to base a certification determination.  In a nutshell, it requires that the organization use “all reasonable sources of information to collect only the information required,” and to share that information within the organization “so as to avoid repeated requests for information from enrollees or providers.”

Management Tips

This is one of those policies in which it is best to take the hint in the Program Guide: “UM organizations may take language from the URAC standards and weave it into their policies and procedures, evaluating it to make sure that it reflects their current way of doing business.”  Make sure, however, that your P&P is clear that your reviewers should request additional medical records if and only to the extent necessary.

Design your P&P to make sure that your organization doesn't make requests for the same information multiple times.  This can happen if information is not shared or if people work in what management consultants call "silos", or parts of the company that do not have regular communication with other parts of the organization.

In our experience as URAC consultants, the most common required change in organization’s policies and procedures on the subject is the elimination of a routine requirement numerically coded diagnoses or procedures.    The standard is quite clear in stating that such a routine requirement is simply not allowed.

URAC Accreditation Tips

The standard carries a weight of 4, and two of its six elements are primary.

The only documents you'll need to submit for desktop review are all the relevant P&Ps.  The onsite review will focus on the UM case file review.  In addition, the reviewer might ask to see documentation of reimbursement to providers for making copies, in order to make sure this is being done according to your P&P.