The Basics

This standard requires that the nurse reviewers have access to one of these three types of healthcare professionals:

• A licensed M.D. or D.O. or
• A licensed healthcare professional in the same category as the ordering provider or
• A healthcare professional in the same category as the ordering provider where the ordering provider is of a specialty that is not licensed.

The most common way to meet this standard is to have the medical director, usually an MD or DO, readily available for real-time consultation with the review nurses.  However, if the organization primarily reviews, say, chiropractic claims, having access to a licensed chiropractor will be the more likely approach.  Finally, in the rare circumstance that the ordering provider's specialty doesn't typically require licensure, it is fine if the UM nurses be able to consult with another such provider.

Management Tips

Double-check the job description of the medical director (or other professional overseeing the reviewers' work) to make sure it describes this oversight and consultative responsibility.  Also make sure that your process for primary-source verification of the professional's licensure is functioning well.  In addition, you'll need to have a fail-safe system to make sure the professional's license doesn't expire without your knowledge.  Finally, it's also is a good idea to impose some sort of requirement, either through P&P or employment contract, on the professional to advise the organization should a licensing board take an action against the licensure status of the professional.

URAC Accreditation Tips

This standard is weighted 3.

Documentation of compliance with this standard typically comes in the form of job description of the supervising/consulting doctor or other healthcare professional.  Make sure that the job description contains the provision of supervisory and/or consulting services to review nurses as one of the responsibilities.

If the medical director or other healthcare professional is not an employee, submit either a contract or policy and procedure that makes clear the supervisory/consulting responsibility required by this standard.

During the onsite review, the URAC reviewer will confirm compliance with this standard through interviews of the UM nurses and the overseeing physician/other professional and through review of case files.