Frequently Asked Questions

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What does the URAC acronym represent?
URAC was originally incorporated under the name Utilization Review Accreditation Commission. That name was shortened to the acronym URAC in 1996 when it began accrediting other types of organizations such as health plans, pharmacies, and provider organizations.

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What is accreditation?

Becoming accredited demonstrates a commitment to ongoing improvement. It is a method by which an independent organization – URAC – uses trained reviewers to examine an organization’s operations and to ensure that they are delivering health care in a manner consistent with national standards.

URAC accreditation consists of a two-part review. It begins with an examination of documents such as those related to policies and procedures (the “desktop review”). Then there is a validation review conducted by URAC’s assigned reviewer(s) and the applicant organization. This determines that the organization is, in fact, operating according to the requirements of URAC’s standards.

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Who does URAC accredit?

Accreditation adds value to organizations that receive it by providing an external, independent seal of approval and by promoting quality improvement within the organization as part of the accreditation review. URAC accredits many types of health care organizations depending on the specific functions they carry out and has a portfolio of programs that spans the health care industry. URAC accreditations, certifications, and designations address health care management, health care operations, health plans, pharmacy quality management, and providers.

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Does URAC offer an accreditation or certification for compounding pharmacies?

No, URAC does not accredit or certify the work done in compounding pharmacies or compounding functions. URAC’s Pharmacy Quality Management® accreditation programs include Specialty Pharmacy, Community Pharmacy, Mail Service Pharmacy, Drug Therapy Management, Pharmacy Benefit Management, and Workers’ Compensation Pharmacy Benefit Management. URAC defines Specialty Pharmacy as a full service pharmacy that specializes in filling prescriptions for patients who need certain high-cost biotech and injectable medications. These specialty medications help patients with complex conditions including multiple sclerosis, rheumatoid arthritis, certain types of cancer, solid organ transplant, and hemophilia. These drugs can be injected, infused or taken orally, and typically require special handling and other specialty expertise.

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What are the general eligibility requirements for all URAC programs?

To apply for URAC accreditation and certification, the potential applicant organization must:
1. Be an established legal entity in the United States (U.S.) including U.S. Territories.
2. Operate under a unique Employer Identification Number assigned by the Internal Revenue Service.
3. Have the ability to produce a Certificate of Good Standing from the U.S. State or Territory where the entity is domiciled.
4. Have the ability to provide proof of having filed applicable federal and state taxes.
5. Sign the URAC contract and pay all fees within the assigned due dates.
6. Be in compliance with applicable U.S. federal, state, and local laws and regulations.
7. Operate under active business and clinical permits, licenses, registrations, or charters, within the scope of accreditation function, that have been legally issued by U.S. federal, state, or local agencies.
8. Perform all clinical services and denials, within the scope of accreditation function, within the U.S. – this includes U.S. territories.
9. Be able to document all non-clinical services, within the scope of accreditation function, that operate outside of the U.S.
10. Perform health care services that can be evaluated, relevant to the URAC program standards applied.
11. Not delegate or outsource to another entity more than 50 percent of the standards within the scope of accreditation function.
12. Operate under the same policies and procedures at all locations covered within the scope of accreditation function.
13. Provide complete and accurate information to URAC during the application process and during the term of the accreditation.
14. Have the ability to report required measurement data.
15. Demonstrate that it continually assesses and acts to improve the quality of its services that are within the scope of accreditation function.
16. Identify any excluded business or customers from the scope of the accreditation function.
17. Not exclude functions for which URAC is recognized by the federal government or state governments.
18. Have less than six months of operations if seeking provisional accreditation.

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How many organizations hold URAC accreditation?

URAC-accredited organizations are listed in the URAC Directory of Accredited Organizations. It can be searched by a specific program or by organization name.

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Who recognizes URAC accreditation?

URAC’s accreditation is recognized nationwide by state and federal regulators. URAC accreditation standards appear in legislation and regulation at the state and federal government. URAC has deemed status for various state and federal programs and is authorized by the U.S. Department of Health and Human Services as an accreditor for Qualified Health Plans in the Health Insurance Marketplace. URAC’s health plan accreditation standards are approved by the U.S. Department of Health and Human Services (HHS) and are valid for health plans in all 50 states as well as the District of Columbia. URAC has recognition of our Health Plan Accreditation from the Center for Consumer Information and Insurance Oversight for Qualified Health Plans being offered on Health Insurance Marketplaces and deeming recognition from the Centers for Medicare and Medicaid Services (CMS) for Medicare Advantage plans (which does not include Part D plans).

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How much does URAC accreditation cost?

The fee to apply for a three-year accreditation is unique to each of URAC’s more than 30 programs. The application fee includes the desktop review, validation review, access to URAC’s application guide, interpretations guide, and educational tutorials to help organizations learn more about the process of accreditation. Once the program application fee has been paid and if accreditation is awarded, there are no annual accreditation fees during the three-year accreditation. For a detailed analysis of your organization’s specific needs, please contact URAC at sales@urac.org.

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Who develops URAC’s standards?

URAC develops its standards based on extensive input from independent advisory committees which are comprised of stakeholders with expertise in the delivery of quality health care. Standards are developed through extensive discussion and are then made available for public comment. This leads to further refinement and is then submitted to URAC’s independent advisory group for approval. URAC’s Board of Directors is responsible for final approval of accreditation standards. URAC’s Board of Directors is specifically designed to ensure diverse representation from throughout the health care industry. URAC’s accreditation programs are reviewed on a regular basis to ensure that our standards are up to date and relevant to industry best practices.

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How often does URAC update program standards?

Generally, URAC updates the standards for its accreditation programs every three years. However, rapid developments in the health care environment may necessitate making a change more often.

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Are URAC’s full accreditation standards and interpretation guide available on the URAC website?

Summaries of URAC standards – known as “standards at a glance” – are available on the URAC website. As of September 2014, URAC only provides full accreditation guides to applicants that have paid for an accreditation program. Accreditation guides are no longer available for purchase by third parties. If you are a URAC applicant or accredited organization, your accreditation guide is available through URAC’s AccreditNet® website portal.

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How soon does an organization have to comply with revised standards?
An organization that has already started an application when URAC releases revised standards will generally be able to choose which standards to use in their accreditation review – the new or the old. When that same organization seeks reaccreditation, it must comply with current standards.

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How do I get started with accreditation?
An organization should first conduct a self-assessment exercise that compares your current operations with those required by URAC standards. Changes may need to be made in your processes, policies, and procedures to ensure alignment. URAC strongly recommends that one or more individuals from your organization attend a URAC educational workshop or webinar so that you understand how to interpret standards and how to organize a successful application.

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How long does an accreditation review take?

The amount of time it takes for an organization to prepare an application for desktop review by an accreditation reviewer may vary depending on whether the appropriate work processes, policies, and procedures are in place. It also depends on the type of accreditation you are seeking. Organizations new to accreditation generally need more time to prepare thoroughly. It usually takes four to six months to complete an accreditation review once URAC receives your completed application.

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What if we have questions while we are preparing an application?
If there are questions about preparing your application for accreditation or reaccreditation, please contact your assigned URAC account manager. For questions specific to a particular standard, questions may be submitted at URAC’s submit an inquiry section of its website or through specific areas available in AccreditNet. After an application is submitted to URAC through AccreditNet, an accreditation reviewer will be assigned to answer questions about the documents submitted during the desktop and validation reviews.

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Who makes accreditation decisions?
Results of the desktop and validation reviews are forwarded to an independent Accreditation Committee. Members of the committee include diverse, independent representatives from across the health care quality industry who have experience with URAC accreditation. Information presented to the committee about each applicant is done in a “blinded” manner so that the committee members are not aware of the identity of the applicant organization.

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What are the accreditation decision options made by URAC’s Accreditation Committee?

Once an application is presented by URAC to the independent Accreditation Committee, it can recommend several alternatives. The committee may grant the applicant organization Full Accreditation, Conditional Accreditation, Provisional Accreditation or Denial. Conditional Accreditation requires that the application organization be reviewed again within three to six months. Provisional Accreditation is given to new organizations not yet able to provide data for a full evaluation. Applicants have the option to appeal accreditation decisions for less than Full Accreditation status. If an applicant organization feels it is unlikely to pass accreditation, URAC allows that organization to withdraw its application through a written request from the organization that includes the reason for the withdrawal.

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What is the difference between Health Plan and Health Network standards?

URAC’s Health Plan accreditation is for organizations that want a comprehensive review of their operations as a health benefits issuer. There are eight sections in the Health Plan standards: Network Management, Quality Improvement, Credentialing, Member Relations, Health Plan Operations, Compliance Program, Mental Health Parity, and Utilization Management (UM). The standards are appropriate for health maintenance organizations (HMO) and other integrated health plans. Health Network accreditation does not include UM requirements, and it is generally more applicable to preferred provider organizations (PPO). It also has a phase-in option before the PPO has to complete credentialing of all providers according to URAC standards. Summaries of URAC standards – known as “standards at a glance” – are available on the URAC website.

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What is the Modular Accreditation System?

URAC’s Modular Accreditation Systems allows for a diverse range of health care organizations to apply for URAC accreditation with the flexibility to achieve accreditation for a wide spectrum of health care organizations and health care-related services. This approach adapts to the continuing evolution of the health care industry. Each module is a set of standards established for a particular health care practice or related function.

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What are the URAC requirements for information technology (IT) security attestation and encryption?

Per the HIPAA Security Rule (and URAC standards), all electronic protected health information (ePHI) created, received, stored, or transmitted by an organization must be protected.

All security measures – including encryption – used for ePHI, both at rest or in transit, must be assessed (i.e., addressed) and documented during the development of the IT risk assessment. Documentation of risk threats, vulnerabilities, and possible impact levels must be submitted to URAC along with current measures in use at the organization to secure ePHI. If any security measure (including any encryption of ePHI, at rest or in transit) is deemed by the organization as “not reasonable or appropriate” to protect ePHI in any system, alternative measures must be deployed to protect the ePHI. What specific measures an organization deploys to secure ePHI is based on the risk assessment evaluation for each individual organization.

URAC requires an attestation, signed by an organization’s security official, that describes the implementation status of its encryption (or other comparable measures) used to protect ePHI at rest and in transit. If the security official deems all measures to protect ePHI at rest and in transit are complete, the attestation (and policies/procedures) would reflect this. If the security official believes that additional measures still need to be deployed to protect ePHI, this information would be reflected in the attestation. In this case, the organization must also submit an IT security plan indicating why any security standard (including encryption) was found to not be reasonable and appropriate, what alternative measures were deployed (or will be deployed and when – including projected dates or time frames for such deployment), and what alternate measures are being used in the interim to protect such ePHI.

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Interested in accreditation?
Contact businessdevelopment@urac.org

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