Health Utilization Management Accreditation Standards Summary

Accreditation Overview.

Most medical care paid for by health insurance undergoes some form of utilization review to determine if the recommended procedure or treatment is medically necessary. As a result, almost every American enrolled in a health benefit plan is affected by utilization review. URAC developed the Health Utilization Management (UM) Standards to ensure that organizations providing utilization review or utilization management services follow a process that is clinically sound and respects patients’ rights.

URAC’s Health UM Standards are applied to a variety of health care organizations, including stand-alone UM organizations and UM functions within health benefits programs, such as indemnity insurance, health maintenance organizations (HMOs) or preferred provider organizations (PPOs).
URAC recently made a number of changes to make its Health UM Standards more compatible with the Department of Labor’s news claims regulation. (See www.dol.gov for information on the DoL claims regulation.)

Please note: In addition to the specific standards described below, organizations seeking Case Management Accreditation must also comply with the Core Standards.

Scope of Services.

The standards apply to the utilization management process, either as a stand-alone function, or as part of an integrated managed care plan, such as an HMO or PPO.

Personnel.

The organization employs qualified utilization management staff that is supported by written clinical review criteria. Non-clinical staff may perform limited data collection, intake screening and scripted clinical screening. At each stage of the utilization review process, the organization must appropriately use qualified clinical staff.

Utilization Management Process.

The Health Utilization Management Standards require an organization to establish and implement a three-step process to determine if a proposed medical treatment or service is medically necessary. Licensed health professionals, such as nurses, must perform the first step -- initial clinical review.

If the proposed service cannot be approved during initial clinical review, then the case must be referred to step two of the process –- peer clinical review. A physician who is qualified to render a clinical opinion about the proposed medical service generally must perform peer clinical review. However, if the treating provider is a non-physician, then a similar provider may also perform peer clinical review. For example, if the treating provider is a chiropractor, then peer clinical review may be performed by a chiropractor. Regardless of the type, a provider who performs peer clinical review must be available to discuss review determination with the treating provider.

As with initial clinical review, if peer clinical review results in a certification, then the utilization management process ends for that case. However, if peer clinical review results in a non-certification, the treating provider and the patient have the right to access step three of the process – appeals consideration. Clinical peers that are board-certified must consider appeals and who are in the same profession and similar specialty as typically manages the medical condition under review and who were not involved in the initial review decision. Either the patient or the treating provider may initiate appeals consideration. For cases involving ongoing or imminent medical care, the organization provides for an expedited appeals consideration mechanism.

Throughout the utilization management process, the UMO utilizes explicit clinical review criteria based on sound clinical principles and processes and are reviewed and revised on a periodic basis. Upon request, the UMO discloses to the patient or treating provider the criteria upon which a non-certification decision was based.

Confidentiality.

The organization must have written policies and procedures in place that assure information obtained during the UM process is kept confidential in accordance with applicable laws. Information must be limited to only what is necessary for UM of the services under review, and be used solely for the purpose of UM, quality management, discharge planning and case management. In addition, if provider-specific data is released to the public, the organization must have policies and procedures for exercising due care in compiling and releasing such data. The policies and procedures address issues such as how data is obtained and verified, how subjects of such disclosures are informed of the disclosures, how potential users of the information are informed about the uses of the data, etc.

CLICK HERE for a list of standards you must comply with in order to obtain accreditation.

Created by Matrix Group International, Inc