URAC

The organization has an ongoing training program that includes:
(a) Initial orientation and/or training for all staff before assuming assigned roles and responsibilities;
(b) Ongoing training, at a minimum annually, to maintain professional competency;
(c) Training in current URAC Standards as appropriate to job functions;
(d) Training in state and regulatory requirements as related to job functions;
(e) Conflict of interest;
(f) Confidentiality;
(g) Training on identification and prevention of fraud and abuse, as appropriate to job functions;
(h) Delegation oversight, if necessary; and
(i) Documentation of all training provided for staff.

Question: Please advise on the frequency and types of training required to meet Core 7c, d, e, f and g. A review of the standard appears to indicate that training during the initial orientation and or general training of Core 7(c-g) is sufficient to meet the standard.  Core 7(b) clearly requires a minimum of annually regarding professional competency.  Is this interpretation correct?

Response: Orientation and ongoing training programs help to ensure that staff are kept up-to-date and have the knowledge and resources to provide quality program services. Training may vary by profession and the type of organization. The standard is silent on frequency of training.

Examples of training include: Obtaining continuing education credits in a relevant field. Attendance at meetings or conferences related to job functions In-house on performance of job functions. Ongoing training should be documented in personnel files. Regarding Core 7(c) and (d): Staff need only be trained in those URAC standards and regulations that apply directly to their job and not all standards and regulations that affect the organization.

The organization designates at least one senior clinical staff person who has:
(a) Current, unrestricted clinical license(s) (or if the license is restricted, the organization has a process to ensure job functions do not violate the restrictions imposed by the state licensure board);
(b) Qualifications to perform clinical oversight for the services provided; and
(c) Post-graduate experience in direct patient care; and
(d) Board certification (if the senior clinical staff person is an M.D. or D.O.).

A senior clinical staff person:
(a) Provides guidance for all clinical aspects of program;
(b) Is responsible for clinical aspects of program; and
(c) Has periodic consultation with practitioners in the field.

Question: With regards to Core Standard 10 and 11, in the interpretive guide it indicates URAC generally expects that the organization providing general health services, products or management, that the senior clinical staff is a MD or DO.  We are sitting for accreditation for case management only. We do have a medical director, but he is contracted to provide services as needed.  We provide case management services; we are not an insurance company nor do we approve or deny services (i.e., perform utilization review).  Do we need to have an MD or DO on staff in the Senior Clinical position?

Response: Fore Case Management organizations, it is not required that the senior clinical staff person be a physician; however, the case management standards require that the case managers have access to a physician that has experience to the type of program under consideration. 

The senior clinical staff person for a Utilization Management program must be an MD or DO for general health and welfare review programs.  In addition, board eligible does not meet Core 10(d).  Though the senior clinical staff person may not work full time, work remotely, or may be a contracted individual instead of an employee, it is incumbent upon the organization to provide evidence that this individual is qualified pursuant to Core 10 and fulfills the accountabilities identified in Core 11.

The organization maintains signed written agreements with all clients describing the scope of the business arrangement.

Question: Do we need to submit a master list naming all of the clients with whom we do business, or are the sample template agreements enough?

The organization:
(a) Establishes standards to assure that consumers or clients have access to services: and
(b) Defines and monitors its performance with respect to the access standards.

Question: As a Health Plan when responding to standard Core 25 when discussing access, is it referring to: A) access to provider networks (MDs, etc.) B) access to our staff and services provided by our staff such as educational materials, information on complaint/appeal rights, etc. C) both of the above. Please clarify the term access as it applies to this standard.

The organization has a quality management committee that:
(a) Is granted authority for quality management by the organization's governing body;
(b) Provides on-going reporting to the organization’s governing body;
(c) Meets at least quarterly;
(d) Maintains approved minutes of all committee meetings;
(e) If applicable, includes at least one participating provider or receives input from a participating provider committee (such as a Physician Advisory Group);
(f) Provides guidance to staff on quality management priorities and projects;
(g) Approves the quality improvement projects to undertake;
(h) Monitors progress in meeting quality improvement goals; and
(i) Evaluates the effectiveness of the quality management program at least annually.

Question: Does the standard require that the organization have one QMC or is it acceptable to have 2 committees, one that monitors operational performance and one that monitors clinical performance?

The organization verifies the following practitioner credentials using primary sources:
(a) State licensure; and
(b) Board certification, if applicable, or highest level of education.

Question: What are the acceptable sources of primary source verification (PSV) for Board Certification?

The ABMS has indicated that two products published by Elsevier Science, "The Official ABMS Directory of Board Certified Medical Specialists" and the CD "ABMS Medical Specialists Plus" as ones that are not to be used for primary source verification (PSV), in part since the complete physician date of birth has been removed from these sources.  I will refer you to the document entitled, “Official ABMS® Display Agent List” dated September 15, 2006, found on the ABMS website:

http://www.abms.org/Who_We_Help/Professional_Organizations/pdf/DisplayAgentList.pdf.  Of note, the ABMS recognizes Elsevier’s “BoardCertifiedDocs” as a service providing primary equivalent source data on behalf of the ABMS.  In addition, the ABMS indicates that it offers a number of alternate PSV source options and is prepared to assist organizations in selecting the one that is best suited for their needs.

The senior clinical staff person:
(a) Provides guidance for all clinical aspects of program;
(b) Is responsible for clinical aspects of program; and
(c) Has periodic consultation with practitioners in the field.

The organization maintains a system to receive and respond in a timely manner to complaints and, when appropriate, inform consumers of their rights to submit an appeal.

The organization maintains a formal appeal resolution process that includes:
(a) Written notice of final determination with an explanation of the reason for the determination;
(b) Notification of the process for seeking further review, if available; and
(c) A reasonable, specified time frame for resolution and response.

The organization reports analysis of the complaints and appeals to the quality management committee.

The organization has a mechanism for consumers to access an independent review process, after all internal appeal mechanisms have been exhausted, for clinical determinations relating to the necessity or appropriateness of medical services (including determinations that proposed medical services are experimental in nature).  Independent review entities:
(a) Must access and rely on appropriate clinical expertise in rendering independent review determinations;
(b) Must not have any direct financial interest in the organization or in the outcome of the independent review;
(c) Render determinations:
(i) For non-urgent cases, within thirty calendar days from the date the consumer initiated the independent review; and
(ii) For cases involving urgent care, within 72 hours from the date the consumer initiated the independent review;
(d) May not have been involved in the original determination under appeal.

Individuals who conduct initial clinical review:
(a) Are appropriate health professionals; and
(b) Possess an active professional relevant license.

Question: Does the URAC Health UM, CM and DM accreditation include staff performing these functions that are telecommuting or working out of a client site?
Response: Yes, staff working offsite – either telecommuting or working at a client site – is included within the scope of the accreditation. URAC reviewers will examine staff files, QM oversight, etc. as it involves this type of staff and URAC reviewers may interview them either telephonically, have them come into the office, or even visit them at their off-site location.

Health professionals that conduct peer clinical review are available to discuss review determinations with attending physicians or other ordering providers.

When a determination is made to issue a non-certification and no peer-to-peer conversation has occurred:
(a) The organization provides, within one business day of a request by the attending physician or ordering provider, the opportunity to discuss the non-certification decision:
(i) With the clinical peer reviewer making the initial determination; or
(ii) With a different clinical peer, if the original clinical peer reviewer cannot be available within one business day); and
(b) If a peer-to-peer conversation or review of additional information does not result in a certification, the organization informs the provider and consumer of the right to initiate an appeal and the procedure to do so.

Question: Does URAC require the offering of a peer-to-peer conversation for retrospective medical necessity denials?
Response: No, standards HUM 15 and HUM 16 apply to the prospective and concurrent review processes where the request for certification is non-certified by a clinical peer reviewer.

As part of the appeals process:
(a) The organization provides the patient, provider, or facility rendering service the opportunity to submit written comments, documents, records, and other information relating to the case, and
(b) Takes all such information into account during the appeals process without regard to whether such information was submitted or considered in the initial consideration of the case, and
(c) In instance of a first level appeal, the organization implements the decision of the first level clinical appeal if it overturns the initial denial.

Definition of Appeal:  Formal request for review of an organizational determination (i.e., services have been denied, reduced, etc.)  Note: Specific terms used to describe appeals vary, and are often determined by law or regulation. URAC’s UM Standards apply to first-level appeal.
Question: Is the UM appeal file review limited to first level appeal, or does it include all levels of appeals?
Response: The scope of URAC’s medical necessity appeal process is limited to the first level of review as indicated by the definition (above) and standard HUM 31(c) (above); therefore, the file review for Health Utilization Management accreditation will be limited to the first level of review.

Appeals considerations are conducted by health professionals who:
(a) Are clinical peers;
(b) Hold an active, unrestricted license to practice medicine or a health profession;
(c) Are board-certified (if applicable) by:
(i) A specialty board approved by the American Board of  Medical Specialties (doctors of medicine); or
(ii) The Advisory Board of Osteopathic Specialists from the major areas of clinical services (doctors of osteopathic medicine);
(d) Are in the same profession and in a similar specialty as typically manages the medical condition, procedure, or treatment as mutually deemed appropriate; and
(e) Are neither the individual who made the original non-certification, nor the subordinate of such an individual.

Question: If new information is received with an appeal request, can a nurse reviewer approve the appeal if the new information meets criteria?
Response: Yes.  Though this process is not specifically addressed in the accreditation guide, it is not prohibited by the standards.  An organization must meet the timeframes required by the standards regardless of any additional steps it may conduct.

Appeals considerations are conducted by health professionals who:
(a) Are clinical peers;
(b) Hold an active, unrestricted license to practice medicine or a health profession;
(c) Are board-certified (if applicable) by:
(i) A specialty board approved by the American Board of  Medical Specialties (doctors of medicine); or
(ii) The Advisory Board of Osteopathic Specialists from the major areas of clinical services (doctors of osteopathic medicine);
(d) Are in the same profession and in a similar specialty as typically manages the medical condition, procedure, or treatment as mutually deemed appropriate; and
(e) Are neither the individual who made the original non-certification, nor the subordinate of such an individual.

Question: What is appropriate specialty matching and does the standard of care in a community factor in?  For instance, in our community we have no endocrinologists so our PCPs generally care for their own diabetic patients, but if that patient is in a teaching facility they might be cared for by an Endo.  If there is an appeal by a specialist for a condition, which is generally treated locally by a PCP, who would URAC like to see reviewing the appeal?

Response: When selecting a physician to conduct a medical necessity appeal, first choice would be a specialist in the area of concern for the appeal, even if the physician requesting the appeal is not a specialist.  Physicians with more general practices (e.g., IM, PCP, FP, etc.) may conduct an appeal if they have experience treating the case under review.  When asked to do a review, physicians will tell you if it is not an area they typically treat, in which case you would select another physician to conduct the appeal.  Also, pursuant to the standard, the selected appeal reviewer is “…mutually deemed appropriate” by your organization and the physician requesting the appeal [HUM 32(d)].  So if there is some doubt, it is perfectly acceptable to discuss the selection with the requesting provider.  Also, general practitioners are not used for appeals and it is not appropriate to have a pediatrician review an adult case.

If an endocrinologist or a PCP is managing a diabetic case and has made an appeal, then an endocrinologist would be first choice to conduct the appeal, an IM or PCP with extensive experience in diabetes would be a second choice.  See additional scenarios below.

Scenario 2: Cardiothoracic surgeon performs CABG, patient is newly diagnosed with Diabetes, Endo was consulted and discharge left up to Endo.  Last day was denied and is being appealed.  What kind of specialist should review?  Endo, IM, FP or GP or Cardiothoracic surgeon?

Response: The issue keeping the patient in the hospital was diabetes, so an endocrinologist would review the appeal for the last day of inpatient stay, or IM/FP with extensive experience in diabetes.  General practitioners are typically not used for appeals.

Scenario 3: Pt. was admitted for Chest pain by IM/GP/FP.  Cardiology was consulted. Discharge by attending left up to consultant.  Day denied and appealed.  Who reviews, Cardiology or IM/ FP/GP?

Response: Medical issue could be reviewed by IM/FP or a cardiologist.  General practitioners are typically not used for appeals.

Scenario 4: Pt admitted with new onset of seizures by IM/FP/GP/Peds.  Neuro consult ordered.  Discharge by attending left up to consultant.  Day denied and appealed.  Who reviews, Neuro or IM/FP/GP/Peds?

Response: Neurologist would conduct the appeal since seizures were the reason for the last inpatient day.  If it was a pediatric patient with seizures, then a pediatrician with experience treating those types of patients could conduct the appeal.

Scenario 5: Can FP review for IM for inpatient appeals or does it have to be IM for IM and FP for FP, etc.  

Response: Internal Medicine should review for Internal Medicine, FP for FP.

Scenario 6: Does the matching have to be MD to MD or can it be MD reviewed by DO, etc?

Response: MD and DO can review for each other.

Scenario 7: Can a general surgeon review a case of a Vascular surgeon?

Response: Did the appeal turn on a vascular issue – such as was the vascular surgery necessary?  If yes, then a vascular surgeon would be appropriate to conduct the appeal.  If more of a general surgical issue, then a general surgeon could review the case.

Scenario 8: Do the reviewers just have to have knowledge in the field or truly be "specialty matched"?

Response: Start with the specialty match – you can’t go wrong there.  Then there are general surgeons and internal medicine where they may have extensive experience in a given area, and as such could be used for the appeal.

Scenario 9: IM admits for DVT.  An inpatient day is denied.  Who can review the appeal?  FP or Peds or does it have to be IM?

Response: IM would be best choice; PCP/FP could be used.  Most primary care doctors will tell you if they do not believe they have the background or experience to review a case.  Peds is not a good choice for adult cases.

Scenario 10: FP admits an adult with Pneumonia.  Day is denied.  Can a Pediatrician review?  Must it be FP?  IM?

Response: Pediatrician is not appropriate for an appeal on an adult case.  FP or IM could review the case.

Scenario 11: A 10-wk pregnant patient admitted with DVT by OB.  Vascular surgeon consults and follows, too.  Who can review case for denied days?  Can FP or Pediatrician review concurrently without consulting with a Like Specialist for advice?

Response: It depends upon the reason for the denial and why patient was kept – was there some other reason for the hospital stay?  If it was determined that the DVT condition no longer warranted inpatient stay, then a vascular surgeon, IM or FP could review.  If there was some other complication related to the pregnancy, then an OB would appear to be appropriate.

Scenario 12: Total abdominal hysterectomy performed by GYN surgeon.  Can general surgeon do the appeal review?

Response: If the general surgeon has experience with abdominal hysterectomies, then yes.

Scenario 13: Pulmonologist admits for pulmonary emboli.  Who must review appeal?  IM, FP, Peds or pulmonologist?

Response: Pulmonologist, IM or FP.  Peds should review for pediatric patients.

Scenario 14: Pancreatitis admitted by FP.  Consulted with a general surgeon, but treated medically.  Who should review appeal?

Response: IM or FP.

Scenario 15: GI hemorrhage admitted by GE.  No surgery was required, just scoping and watching. Who should review appeal?  GE, surgeon, IM, FP, Peds?

Response: GE, surgeon or IM.  FP if experience with these types of cases.  Peds should not review adult cases.

Scenario 16: Can a Pediatrician review cases on adults that were admitted by IM or FP or specialists?  Can FP do reviews on neonates being cared for by neonatologists?

Response: No to both scenarios. 

Individuals who directly supervise case management practices:
(a) Have at least one of the following qualifications: (Primary)
(i) A bachelors (or higher) degree in a health-related field and licensure as a health professional
(where such licensure is available); or
(ii) Certification as a case manager; or
(iii) Professional certification in a clinical specialty and at least three (3) years experience as a
case manager; and
(b) If they have directly supervised the case management process for three or more years, hold a
certification as a case manager.

Question: CM 4 Interpretive Information/Commentary states: "A list of acceptable 'certifications as
a case manager' will be posted on URAC's Web site at www.urac.org." I have searched the
URAC Web site
and cannot locate this list. I would like to be able to include it in our updated manual for Case
Management Staff.
Response: The link has been updated on the Web site to: http://webapps.urac.org/CMcertifications.asp

Individuals who directly supervise case management practices:
(a) Have at least one of the following qualifications: (Primary)
(i) A bachelors (or higher) degree in a health-related field and licensure as a health professional (where such licensure is available); or
(ii) Certification as a case manager; or
(iii) Professional certification in a clinical specialty and at least three (3) years experience as a case manager; and
(b) If they have directly supervised the case management process for three or more years, hold a certification as a case manager.

Question: CM 4 certification requirement requires individuals who directly supervise case management practices, who have directly supervised the case management process for three or more years to obtain certification as a case manager. The questions are as follows:
1. If a supervisor has directly supervised the case management process for three or more years in another program that is not currently URAC accredited and that supervisor is subsequently assigned to the case management program that will come under URAC view in 2008, does the three years prior supervision count and therefore, certification as a case manager would be required, or does the assignment to the URAC case management program scheduled for review in 2008 count as the first year supervising the case management process?
2. Is “care manager certification” equivalent to case manager certification? Care manager certification is more often associated with licensed social workers and psychologists than with the certified case manager program.
Response:

1. Pursuant to the Guide, “Points to Remember” second bullet: In CM 4 (b), the CM certification requirement applies to individuals who have held the position of a case management supervisor in the applicant organization for 3 or more years. If the individual has held the position of case management supervisor for less than 3 years at the time of application review, this standard is non-applicable.  
2. Care manager certification is not equivalent; the standard is specific to case management certification.   
   

Question: Our organization recently went through a downsizing leaving us with one Nurse Case Manager who is our Case Management Supervisor. As a result, the Director of Quality Assurance assumed responsibility for auditing the Nurse Case Manager claims.  Is this arrangement sufficient for purposes of meeting the intent of CM 9?  If not, do you have recommendations for meeting the intent of this standard?
Response: It is acceptable for the Director of Quality to perform quality audits for case management.

The organization establishes, implements, and educates case management personnel, no less than annually, on policies and procedures supporting the ethical framework for case management practice including:
(a) Advocacy for consumer needs;
(b) Guidance for professional relationships with consumers;
(c) Prohibition of relationships that could compromise professional objectivity;
(d) Resolution of conflicts of interest between the case manager, consumer, third party payer, provider or other entity;
(e) Business, financial, and marketing practices;
(f) Resolution of perceived lapses in quality of care resulting from actions by consumers, payers, case managers, providers, organizations or other entities affecting the case management process;
(g) Policies that address case managers’ handling of consumer needs when such needs extend beyond the scope of the organization’s services;
(h) Prohibition of discrimination against a consumer or group of consumers by the case manager or organization; and
(i) Information on how policies regarding the ethical framework will be shared with staff, contractors, clients, and consumers.

Question: I am inquiring if URAC has a point of view or process guideline related to telephonic case managers who also perform formal state utilization review as part of their work in workers compensation cases. I know, for example, from a regulatory perspective case managers cannot do UR on their cases in Massachusetts, but was wondering what the professional/accreditation perspective was if there is not otherwise prohibited by the state.
Response: Pursuant to the URAC Guide “Interpretive Information/Commentary” for standard CM 12, if the Case Manager is involved in benefits determinations, safeguards should be put in place to assure that the role of advocacy is not compromised. Examples include conducting interviews and case file review.  Most organizations conduct an annual review of the organization’s ethical framework for case management practice (along with review of confidentiality policies).  This annual review, which must address all sub-elements in the standard, is documented in each case manager’s file or an attendance sheet is kept to document the review.

The organization establishes and implements a policy regarding consumers’ consent for participation in case management activities that:
(a) Requires documentation of oral consent;
(b) Requires at minimum an attempt to obtain written consent;
(c) Indicates the time frame in which the consent(s) must be obtained; and
(d) Indicates the duration of validity of the consent(s).

Question: We currently obtain oral consent from individuals we are case managing. This oral consent is documented in our system.  In order to comply with standard CM 16, do we also need to make an attempt to obtain written consent? If so, does URAC have an example of a consent form?
Response: Yes, you must also make an attempt to obtain written consent pursuant to CM 16(b).  Most organizations are meeting this standard by sending out a consent form for case management with an introductory packet. The organization must establish written guidelines for obtaining consent and may allow that consent is not obtained in every case.  If the organization allows exceptions from consent requirements, it should be prepared to justify those exceptions for quality of care, legal, or other valid reasons on a case-specific basis.  It is expected that this consent is obtained from the consumer (patient), but may be from a family member in extenuating circumstances, (e.g., patient is unconscious, a minor, or determined not legally competent).

Disease management practices for each clinical condition are based on scientific evidence and includes input from clinical content expert(s) one of which must include a provider in the specialty area, that:
(a) Is reviewed annually and updated as needed;
(b) Review applicability of clinical practice guidelines to the specific program design;
(c) References publicly available clinical practice guidelines and evidence-based reports that can be accessed by or provided to participating providers; and
(d) Is the basis for establishing the disease management program's objectives for evaluation, clinical quality improvement, consumer education, and outcomes measurement and reporting.
(e) If the program guidelines are modified, a content expert with expertise in the relevant clinical condition(s) must review the guidelines.

Question: Our URAC Workgroup would like a clarification of Disease Management Standard 2 Evidence-Based Practice. In the Scope of Standards section for DM 2 it states "…the applicant must be able to document compliance with this standard for every disease state for which it markets a ‘disease management program.’  The applicant may exclude disease states from the application if compliance cannot be demonstrated.”  Does this mean that only disease states listed on the application may be included in marketing materials?

Response: Standard DM 2 applies to all disease states included within the scope of the accreditation, which may or may not include all of those that your organization offers to the public.  An applicant may choose not to include every disease state program that it currently offers to the public (i.e., includes in its marketing materials).  Note that organizations cannot use the DM accreditation seal to market a disease state that is not within the scope of their accreditation.

The disease management program defines the allowable scope of activities for licensed or certified clinical staff and non-licensed or non-certified non-clinical staff in carrying out its disease management activities that:
(a) Is consistent with standards of practice for licensed personnel;
(b) If applicable, allows non-clinical staff to conduct intake, non-clinical data collection, and scripted clinical data collection using appropriate documented instructions and scripts;
(c) Prohibits non-clinical staff from conducting evaluation or interpretation of individual clinical data; and
(d) Provides for supervision of non-clinical staff in the disease management program by licensed or certified staff.

Question: Can a Disease Management program use certified health educators instead of registered nurses (RNs) in their counseling models?
Also, can non-clinical staff collect clinical information and complete general assessments?
Response: Scope of practice for any staff member must be consistent with state professional licensure regulations, certification standards of practice, and federal law. Telephonic programs that interact with callers from various states should determine whether or not additional state licensures are required for the clinical staff. Companies must define the scope of services for clinical and non-clinical staff, as well as the oversight process for staff. Companies that use staff with specialized training should develop criteria for use of these staff members. Specialized training may include board certification, or other certifications of training in health services delivery or health education, for example, nutritionists, certified diabetes educators, physical therapists, or child health specialists. Scope of practice for any staff member must be consistent with state professional licensure regulations, certification standards of practice, and federal law.
Per standard DM 6(b), non-clinical staff may only collect clinical data via “…scripted clinical data collection using appropriate documented instructions and scripts.”  Non-clinical staff may not conduct assessments pursuant to standard DM 6(c), where non-clinical staff is prohibited from conducting evaluation or interpretation of individual clinical data.  Non-clinical staff may not conduct general, free-form assessments and deviations from the script are not allowed.

The disease management program develops or adopts an outcomes measurement methodology for measuring condition specific and overall program performance using valid techniques that address:
(a) Sources of data that will be used to calculate the measurements;
(b) The baseline measurement period and time frame for analysis;
(c) The formula by which the measurement is calculated;
(d) Adjustments that will be made in calculating measures and reporting data; and
(e) Frequency of reporting, which must be at least annual.

Question: What are the specifications for URAC's DM performance reporting on outcomes measures?
Response: URAC is not prescriptive as to the specific fields or format for performance reporting; however, the Disease Management Association of America (DMAA) has various publications for measuring outcomes www.dmaa.org.  For each condition, documentation of specific measurement objectives consistent with identified evidence-based guidelines is one of the expected types of information to be included in the reporting.  URAC will verify that the disease management program documents its general methodology for each type of performance measure and documentation for standard DM 8 should address the methodology for measuring performance in clinical, financial, consumer reported and provider performance domains.