URAC Health Utilization Management

3 easy steps to begin your URAC accreditation

Obtain the standards at the URAC store
Request a consultation
Sign the application agreement for accreditation
Sign the application agreement for accreditation

Overview

URAC is widely recognized by nearly every state and the federal government for our health utilization management accreditation program.

With our origins in utilization review and utilization management, URAC set the bar for Health Utilization Management (HUM) in 1990 with the development of the country's  first utilization management accreditation standards. Now, URAC-accredited organizations serve patients in every state across the country.

URAC’s accreditation program assures the clinical and operational soundness of your health utilization management process by evaluating it against a stringent set of nationally recognized standards. With URAC’s HUM standards, organizations maintain the highest confidentiality and avoid conflict of interest in UM processes to protect all parties–patients, providers and payers.

Our program continues to evolve as the health care landscape changes. Traditionally, UM focused more on cost containment methods; it is now seen as a valuable tool to ensure accessibility, quality and timeliness of care. With input from industry experts and valued clients, we have conducted numerous revisions to the original standards. This way, we keep pace with the changing health care industry while defining best practices grounded by real experience.

URAC Health Utilization Management Accreditation is the industry standard; it indicates your organization performs its utilization management functions in an effective, transparent and efficient manner.

Modular Approach

URAC offers five modules to address the HUM functions performed by each organization, giving you the option to choose the one(s) most applicable to your business operations.

The five HUM modules are:

  1. Pre-Review Screening– also known as “initial screening” where staff receive the right information and support to provide excellent customer service
  2. Initial Clinical Review– qualified professionals render certifications or move the review to the next level in a timely, responsive manner
  3. Clinical Decision – promotes an effective and efficient utilization management process, optimizing workflow and outcomes
  4. Clinical Review Criteria– used in the evaluation of medical necessity, criteria are regularly and rigorously reviewed by clinicians with appropriate credentials and experience
  5. Comprehensive – an organization that performs all of the functions in the other modules, as well as conducts appeals.

Review our Standards-at-a-Glance for more details. Once you fill out the "Let's Talk" form, our team can help you decide which module(s) are right for you. Applicant organizations may apply for up to four of the functional HUM Modules or the Comprehensive Module.

Benefits of HUM Accreditation

Earning the URAC Health Utilization Management Accreditation Seal is a mark of distinction for organizations that demonstrate their commitment to quality and HUM accountability. It also boosts your credibility among key stakeholders: patients, provider practices, facilities and purchasers. Additionally, URAC accreditation:

  • Ensures the provision of consistent, unbiased medical necessity determinations by appropriately credentialed staff
  • Enhances your ability to improve the quality and effectiveness of patient care while eliminating unnecessary treatment and expense
  • Helps you protect patient safety and mitigate risks such as contraindicated treatments, adverse drug interactions or inappropriate treatment
  • Validates compliance and adherence to applicable state and federal regulations
  • Implements risk management oversight and review protocols that help mitigate your organization's liabilities
  • Develops a roadmap for ongoing UM process and quality improvements rooted in evidence-based treatment guidelines that enhance care delivery, lower overall health care costs and optimize operational efficiencies

In addition, URAC’s Modular approach means your HUM-accredited partners do not have to conduct delegation oversight; they will use your accreditation instead. This makes your organization an easy choice when they are selecting a service provider or delegated entity.

What to Expect

Within six months or less, we will provide an impartial evaluation of your utilization management program. While our experts define the standards of excellence for HUM programs, they do not prescribe how organizations must meet those standards.

URAC’s thorough approach to accreditation stimulates utilization management program best practices, through email, conference calls and educational webinars.

URAC Health Utilization Management