The Basics

This standard simply notes that state and/or federal regulations are likely to bear on the details of your appeals process, and requires that you coordinate your process with the applicable regulations.  These regulations may vary from jurisdiction to jurisdiction, so you'll need to watch for such variations in the way you handle appeals.

Management Tips

Take the pressure off your staff members by incorporating the regulatory requirements into your P&Ps.  If you have multiple regulators, you may need a reasonably sophisticated system to handle this in a way that makes it easy for your staffers to comply with the applicable laws in all cases.

URAC Accreditation Tips

The sole element of this standard is weighted 4.

As with the other appeals standards, submit your appeals P&Ps and template correspondence dealing with appeals.

The onsite review will bore in on the case files that have been appealed.