The Basics

This is the first of a series of standards that require the establishment and maintenance of a system of appeals of denials of certification requests.  This introductory standard sets forth a few general requirements for your UM appeals system and leaves the detailed requirements for that system to the subsequent standards.

This standard's general requirements are:

• The appeals system must address both urgent and non-urgent situations
• The appeals P&Ps must describe the appeals rights of the patient and any involved providers, including facilities
• The appeals P&Ps must describe the time frames for each component of the appeals process
• The appeals P&Ps must be available to any requesting patient or provider

Management Tips

We cannot stress enough the importance of having a P&P to cover appeals and to have a system for making it available.  Here's a good way to analyze your readiness for this standard:

Are your policies and procedures describing your non-certification appeals process available upon request to any patient, provider, or facility rendering service?

If you answer "yes" to this question, you're only partly on your way to meeting the requirements of this standard. One more question to go:

Does your P&P say that it's available to any consumer, provider, or facility?

If you say "no" to this question, it's time to revise your policy.

The standard requires that you have a "formal process" for appeals of non-cert decisions.  The process must be based in a P&P that (and the standard is quite explicit about this) any patient, provider, or facility involved in the patient's care may obtain upon request. 

Remember, in the world of URAC (or any other accreditation program), if it isn't documented, it isn't happening. So, it is not merely enough that you P&P is available, but it must say that it's available. And, you must submit this documentation with your application in order to avoid getting a comment from your reviewer asking for more documentation.

One other thing -- make sure you have an effective tracking system that allows you to retrieve UM denials that have been appealed, and to distinguish those cases in which the denial is upheld from those in which the denial was overturned.

URAC Accreditation Tips

All the elements are of this standard are mandatory.

For the desktop review phase, submit both your UM appeals P&Ps and a template for any correspondence relating to appeals.  

The onsite review will focus on the case file review and staff interviews.