Dental Plan with Health Insurance Marketplace (HIM) 7.2

DPHIM-NM 13 - Participating Provider Violation Mechanism

Submited by: Tom Goddard

The Basics

The standard requires that your organization implement a means of addressing alleged violations by participating providers in its network of the organization's requirements for providers. The standard applies only to providers already in your network, not merely applicants for participation in the network. 

Management Tips

Standard is the first in a series of standards addressing provider dispute resolution. The standards apply only to participating providers. Furthermore, the standards do not require of the organization to provide dispute resolution mechanisms if the contract with the provider is clear and states that in the event of the revocation of medical licensure is not subject to the dispute resolution process.
It is also important to note that this standard and the ones that follow do not apply to appeals of denials of requests for certification legalization management process. Those disputes are handled in the health utilization management accreditation standards.

Accreditation Tips

Desktop Review
Submit your policies and procedures for provider dispute resolution.
Validation Review
The reviewer will conduct interviews of the medical directors overseeing provider dispute resolution, as well as other members of network management in order to assess whether they understand the dispute resolution processes of your organization.
Document Reviews
You will need to provide your reviewer with a list of provider disputes within the scope of this standard and the ones that follow. Be sure that such a list allows the reviewer to distinguish between disputes arising out of purely administrative matters from disputes involving quality of care, professional conduct, or participation in the provider network. From that list, the reviewer will select files of both types in order to see if you're implementing policies and procedures that comply with URAC's requirements.

  • IRO Core 3.0 / 12.28.2017

    IRO CORE 38 - Consumer Safety Mechanism

    One of the most important of the URAC standards is this one, which requires that the organization have processes to respond quickly to urgent situations that threaten consumers' well-being.Even though the standard speaks of "a mechanism", the reality is that it requires a system of mechanisms dealing with the full array of urgent situations that are likely to confront the applicant. You can see th...

  • IRO Core 3.0 / 12.28.2017

    IRO CORE 33 - Financial Incentive Policy

    This standard says, essentially, that if the organization has a system by which people are provided financial incentives that are based directly on consumer utilization of healthcare services, there must be mechanisms in place to make sure that these incentives don't end up compromising consumer care. This policy includes capitation of providers. Not all URAC reviewers over the years have interp...

  • IRO Core 3.0 / 12.28.2017

    IRO CORE 32 - Senior Clinical Staff Responsibilities

    The senior clinician whose qualifications are set forth in Core 31 must, according to this standard, provide guidance and be responsible for all of the clinical aspects of the organization's program being accredited. In addition, the senior clinician must have periodic consultation with individuals in the field or licensed to deliver healthcare services without supervision, i.e. practitioners. F...