The Basics

Under this standard, if anybody (patient, physician, ordering provider) so requests, the organization must provide the clinical rational for its denial of the request for certification.  The clinical rationale clarifies the clinical reason for the non-cert decision.  It must relate specifically to the patient's condition and/or treatment plan.

It is not enough to simply refer generally to the clinical criteria.  Rather, the rationale must relate the patient's condition to the criteria, and provide enough information for the patient to pursue an appeal of the decision if he/she so desires.

Management Tips

You will recall that the notice of non-certification, which we discussed in an earlier page, requires that patients and providers be notified of their right to the clinical rationale.  So, integrate the P&P for that standard with the P&P for this one.  As that earlier page noted, it may be that the UM program will not have to have a separate process for providing clinical rationale if it does so in the non-certification letter. 

URAC Accreditation Tips

This standard is weighted 4.

Documentation for AccreditNet is straightforward -- submit the P&P describing the process plus a copy of a template letter for providing the clinical rationale.  

The onsite reviewer will interview staff members and look at case files to document implementation of the P&P.