The Basics

This standard is limited to retrospective review.  In making the certification decision, the organization may only use the information that was available at the time the services were rendered to the patient.  In other words, there can be no "Monday morning quarterbacking," in which you use information acquired more recently than the rendering of the service to determine whether it was medically necessary.  

Management Tips

This is designed to protect providers from the unfair situation of being denied payment because the decisions they made in good faith given the information they had turned out to be incorrect, at least when viewed with the 20-20 vision of hindsight.  The same P&P you use for the previous standard is an excellent place for this language, as well.  Because it is a bit counterintuitive for some people, it is probably worth emphasizing this requirement in staff training.  

URAC Accreditation Tips

The standard has a weight of 4.

The P&P on this topic will be the only required documentation.  

This is likely to come up in the onsite review only on review of case files and in interviews of peer reviewers and the UM staff.