URAC UM 30-35 -- Are the providers' appeal rights independent, or based on the consumers' rights?
Submitted by Tom Goddard on Tue, 2009-04-07 07:23
We received this question from a URAC-accredited company: Under URAC's utilization management appeals policies, are the providers' rights to appeal a non-certification decision based upon the patients' rights to appeal, or are they independent of the patients? It seems pretty clear to me that the provider has an independent right to appeal, and need not be pursuing an appeal on behalf of the patient.
There is no language in any of the URAC HUM appeals standards that limits a provider's pursuit of an appeal from a non-certification to instances where the provider is appealing on behalf of the patient. On the contrary, URAC makes it clear that the patient and the provider have a right to appeal, nowhere describing the provider's right as derivative:
HUM - 30 - Non-Certification Appeals Process
The organization maintains a formal process to consider appeals of non-certifications that includes:
* * *
(b) Written policies and procedures that:
* * *
(iii) Are available, upon request, to any patient, provider, or facility rendering service.
HUM - 31 - Appeals Process
As part of the appeals process:
(a) The organization provides the patient, provider, or facility rendering service the opportunity to submit written comments, documents, records, and other information relating to the case . . ..
In addition, there is no distinction made between patient and provider in the notification standards, HUM 33-35.
Further, I have found no language in any of the interpretive material accompanying these standards suggesting that the provider's appeal rights arise only if exercised on behalf of the patient.
Based upon all this, I believe it is fair to conclude that providers and patients stand on equal ground when it comes to medical necessity appeals, each having an independent right to exercise the appeal rights guaranteed by the URAC HUM standards.