The Basics

This standard prescribes the minimum requirements for the written notice of an adverse appeal decision (one upholding the initial denial of the request for certification):

• It must be sent to the patient and ordering provider or facility
• It must state the principal reasons for the decision
• It must state that your organization will provide the clinical rationale underlying decision in response to a written request
• It must describe any additional appeal mechanisms and how to access them, if they exist

Management Tips

See the earlier standard on the notice of denial of certification for a full discussion of the principal reason and clinical rationale issue.  The same issues that apply to that letter apply to this letter.  Make sure the case files contain the written notice and that it is dated.

URAC Accreditation Tips

The standard is weighted 4, and the elements are primary except for the offer of clinical rationale.

Again, the appeals P&P and applicable templates are what you submit to AccreditNet.

The onsite reviewer will focus on appeals case files and staff interviews.