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URAC’s Health Utilization Management Accreditation

URAC is the leader in Health Utilization Management Accreditation (HUM). Since creating the first standards twenty years ago, URAC has set the bar for health utilization review. Recognized for meeting filing requirements with the State Departments of Insurance, URAC’s HUM Accreditation continues to transform the industry with each new revision of the standards. HUM Standards ensure that all types of organizations conducting utilization review follow a process that is clinically sound and respect patients’ and providers’ rights while giving payers reasonable guidelines to follow. Standards address the use of evidence-based guidelines, incorporation of adherence guidelines, and evaluation of utilization rates to meet the demands of a changing health care system. Cost effective care with optimal outcomes reinforces the value and importance of health utilization management across the health care continuum including health plans, hospitals, specialty care for mental health, and long term care. URAC’s Health Utilization Management standards address:

• Medical necessity criteria that is evidence based and promotes consumer safety;
• Specialty matched clinical peers for medical necessity review;
• Requirements for consistency in maintaining the highest confidentiality in UM processes as we approach a new age with electronic health records (EHR) and health information exchanges;
• The need for flexibility for stand-alone UM organizations and UM functions within health benefit programs such as indemnity insurance, health maintenance organizations (HMOs), preferred provider organizations (PPOs), Consumer-Directed Health Care plans, third party administrators (TPAs);
• Specialty UM organizations, such as mental health, dentistry, physical medicine rehabilitation, genetic testing, and hospitals.

Societal, economic, and regulatory factors are driving employers, purchasers and managed care organizations to increase access, improve outcomes, and manage costs for mental health and substance abuse treatment. The 2009 Federal Mental Health Parity and Addiction Equity Act (MHPAEA) creates many important issues that must now be considered by plans and payers. This Act, also referred to as the Wellstone-Domenici Parity Act, went into effect on January 1, 2010. Under the law, employers that offer mental health benefits cannot require higher co-pays or more restrictive treatment limits on mental health and substance abuse treatment compared to medical and surgical treatment. Utilization Management, as well as Case Management and Disease Management, will play a critical role in the evaluation and review of appropriate patient care and utilization for mental health and substance abuse services for assuring alignment with the law.

URAC’s accreditation assures the adequacy and quality of your health utilization management program through evaluation against broadly recognized standards and measures.

Become Accredited Now! Demonstrate your readiness to comply with the Federal Mental Health Parity and Addiction Equity Act by implementing effective health utilization management across the spectrum of care. For more information, visit businessdevelopment@urac.org or call 202-216-9010.