Health Network 7.1

N-NM 16 - Disputes Involving Administrative Matters

Submited by: Tom Goddard

The Basics

This standard requires that your organization have a mechanism for disputes with providers in your network for largely administrator disputes. Essentially, any provider disputes that are not covered by the previous standard or by the health utilization management appeals standards are covered here.
The mechanism that your organization is required to have for such disputes is simply the right to bring the dispute to a representative of the organization authorized to hear such disputes who was not involved in the original decision under dispute.

Management Tips

In addition to making sure that your policies and procedures appropriately describe the administrative dispute resolution process, you'll need to make sure that you have a mechanism for tracking such dispute resolution processes. And addition, staff will need to be trained on the documentation of such disputes. Many organizations that have such mechanisms have struggled with a standard because the mechanisms for documenting dispute resolution are incomplete.

Accreditation Tips

Desktop Review
Submit policies and procedures that describe the administrative provider dispute resolution process. Unlike the provider dispute resolution processes covered by the previous standard, which are relatively uncommon, administrative disputes with providers are very common. It is highly unlikely that you have no such disputes. Therefore, URAC will expect you to submit blinded samples of provider requests for dispute resolution, as well as blinded documentation of how that process works, including committee meeting minutes if any such meetings are part of the process.
Validation Review
Document Review
Be sure to have prepared for the first day of the URAC validation review a comprehensive list of administrative disputes with providers for the entire period under consideration for this accreditation review. The reviewer will select from that log a sample of provider disputes, and examine the files for those disputes to test compliance with your policies and procedures as well as the standard. Be sure that the log gives the reviewer an idea of the topic under dispute for each of the disputes.
The reviewer will interview nickel and not clinical leadership of the network management program regarding administrative disputes with providers.

  • Independent Review Organization: Internal Review 5.0 / 11.28.2017

    IR-INT 5 - Internal Review: Additional Reviewer Qualifications for Appeals

    IROs must have more rigorous qualifications for reviewers handling appeals. In addition to the requirements outlined in the previous standards, reviewers handling appeals must be board certified, if an MD, DO, or DPM.

  • Independent Review Organization: Internal Review 5.0 / 11.28.2017

    IR-INT 4 - Reviewer Qualifications

    Under this standard, the IRO must establish qualifications for its reviewers. At a minimum, those requirements must include the following:Current, non-restricted license or certificate as required under U.S. law for clinical practice;At least five years FTE experience with direct clinical care;Must be a clinical peer (i.e., "a physician or other health professional who holds an unrestricted licens...

  • Independent Review Organization: Internal Review 5.0 / 11.28.2017

    IR-INT 3 - Credential Status Changes

    This standard requires that the IRO have and implement policies and procedures that both require the IRO's staff members to notify the IRO in the event there is an adverse change in the status of the staffer's license or certification (including board certification) andprovide a procedure to implement a corrective action plan in the event of such an adverse change.In other words, if a member of th...