The Basics

This standard addresses the issue of who may initiate a request for certification.  In a nutshell, it requires that your organization allow any "appropriate" person to start the process.  That could be the worker or his/her representative, or even a claims adjustor, state regulator, or the provider (including the facility rendering service).  What determines who is appropriate to start the utilization management process can be state law, the insurer or the claims administrator.  In fact, it may be the mere report of the injury that triggers the process.

So, if your organization operates in several states, or serves several insurers or administrators, it could have a pretty broad array of parties who can legitimately initiate the request for certification.  The safest bet is to assume that any of the possible initiating parties mentioned, above, is "appropriate" and has the authority to request certification.

Management Tips

The key to this standard is to make sure your P&P regarding the initiation of a request for review is sufficiently broad to include all the appropriate persons.  As you're drafting the P&P, make sure you consult not only the laws and regulations that affect this part of the process, but also any requirements by your clients, whether they be insurers or TPAs.  

It also will be important to make sure that your staff is trained on this P&P regarding who can initiate a request for certification.

URAC Accreditation Tips

This standard carries a weight of 4.

The documentation requirements for AccreditNet are straightforward: submit your P&Ps covering who may start a request for certification and from what sources your organization will receive information in connection with its certification review.

The onsite review will involve an examination of your UM files and interviews with the UM staff members.