The Basics

This mandatory standard summarizes in only ten words the core of URAC's concern about non-clinicians' involvement in utilization management:  They simply must never issue a denial of a request for certification.

Period.

This prohibition includes the selection of criteria for a particular case.  Furthermore, the amount of automation involved in the process is irrelevant -- no clinical evaluation may be conducted by non-clinicians.  

Management Tips

The safe approach to this standard is to make sure that both your P&Ps and your staff training are explicit in requiring that non-clinicians do no activities that require the interpretation of clinical information.  

While it is easy to make sure your P&Ps and job descriptions comply with this standard, it is sometimes more difficult to make sure the entire staff is on board.  Veteran non-clinicians, or clinicians who don't currently have a valid clinical license, have been known to step over this line and make an occasional clinical assessment.  This is a very bright line for URAC, though, so it is incumbent on the organization to make sure it never happens, regardless of how well-trained or how experienced the non-clinician is.

URAC Accreditation Tips

This standard is mandatory.  

Documentation of this at the desktop stage is simple -- submit the P&P that you already submitted for earlier standards that clearly describe the non-clinical nature of the job functions performed by your non-clinical staff.  

In addition to the staff interviews, which are the most critical component of the review for this standard, reviews of case files also will be a part of the URAC onsite review process.  Documentation must be crystal clear that the non-clinician is involved only in purely administrative matters.