The Basics

This standard places strict limitations on what non-clinicians (i.e., the administrative employees) in the UM program may do.  The short version is that they should never be put in a situation of evaluating or assessing clinical information.  For the most part, they shouldn't even touch clinical data.  Tasks should be limited to collecting non-clinical information and responding to service requests that have nothing to do with clinical evaluations.  The only occasion in which non-clinicians should touch clinical data is if they are collecting it in a structured format (e.g., tightly supervised scripts or automated mechanisms for collecting clinical data.

This standard is the first of a trio of standards designed to set clear restrictions on the use of non-clinical personnel in the review process.  As the Program Guide notes, it applies to all review processes, regardless of the degree of automation, that do not involve clinical judgment and that do not result in non-certification determinations.

Management Tips

Managers will need to make sure that your P&P on this topic explicitly outlines the responsibilities of non-clinical review staff, their reporting relationships, and scope of work.  You should also make sure your non-clinical staff members' job descriptions are clear in communicating that they are not involved in clinical evaluations.

URAC Accreditation Tips

The standard is weighted “4”, and subsections (a) and (d) are primary elements.

Documentation for desktop review includes your P&Ps on the topics and sample job descriptions of your non-clinical staff members.  It also is a good idea to submit sample scripts or algorithms for non-clinical review.

The on-site review will focus on interviews, demonstrations of any automated systems, and a review of sample scripts or algorithms.  More importantly, the URAC reviewer will be examining case files or evidence that the P&P regarding non-clinical staff involvement is strictly followed.

Do not be misled by the fact that the standard is weighted “4”.  It is inextricably linked to UM 9, which is weighted “5” and is therefore a mandatory standard.  Problems with compliance with UM 7 likely will trigger noncompliance with UM 9, destroying any chance your organization has of attaining full accreditation.