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URAC Seeks Public Input on New Uniform External Review Standards for Health Plan and Health Utilization Management Organizations

Thursday, July 16th, 2009

Public Comment Period Open for New Standards Aligned with NAIC Model Act

Washington, D.C.July 16, 2009 URAC, a leading health care accreditation and education organization, today requested public input on a proposed new, optional set of standards for its Health Plan and Health Utilization Management accreditation programs.

These new “Uniform External Review” standards reflect provisions in the Uniform Health Carrier External Review Model Act, which the National Association of Insurance Commissioners (NAIC) adopted in June 2008. URAC encourages purchasers, policy makers, consumers, health care management organizations and health plans to review the new URAC standards and provide feedback now through August 31, 2009.

“NAIC developed the Model Act to achieve a national standard and uniform approach for processing, conducting, and making external review determinations for insurance coverage,” said Joel Ario, Pennsylvania Insurance Commissioner and Vice Chair, Health Insurance and Managed Care (B) Committee of the National Association of Insurance Commissioners (NAIC). “The Act, in essence, provides a common process for approving independent review organizations in every state that can reduce health care confusion for consumers. URAC’s accreditations and standards have been instrumental in our effort to streamline this process.”

While 45 states have external review laws, there is little uniformity among the states regarding external review processes. The NAIC’s Model Act addresses these variations by establishing standardized protocols for external review, a process designed to ensure that consumers have an avenue to seek an independent review of a health insurer’s denial of benefits for specific procedures or services.

“URAC has always been focused on setting clear, high quality standards for managed care providers. We support NAIC’s Model Act, and wanted to be sure that our criteria for Health Plan and Health Utilization Management accreditation accurately addressed the NAIC policies,” said Doug Metz, DC, Chair of URAC’s Health Standards Committee and Executive Vice President and Chief Health Services Officer for American Specialty Health. “The consumer protection and transparency needed when seeking an independent review of claims was also important to include in the URAC standards.”

So far, two states have enacted legislation comparable to the Model Act. Governor C.L. Butch Otter signed the Idaho Health Carrier External Review Act (HB 192, 2009) on April 1, 2009. And, on May 20, 2009, Governor Jodi Rell of Connecticut signed Senate Bill 959, the State’s version of the Model Act.

“As we move toward enhancing and streamlining healthcare in America, standardization of independent medical peer review processes, timeframes, methods, and credentialing requirements across the United States is an important issue,” said Jeffrey L. Gabardi, Senior Vice President of State Affairs for America’s Health Insurance Plans (AHIP). “We applaud URAC for enhancing its standards to provide an avenue for health carriers to achieve independent verification that they are abiding by the Model Act.”

In addition to its call for public comments on the Web, URAC will conduct focus group meetings on August 6, 2009 and on August 27, 2009 from 2 – 4 p.m. EDT to review standards and educate organizations regarding URAC’s strategy for the new, optional standards. Both Health Plans and Health Utilization Management organizations and regulators will be invited to attend.

URAC’s proposed new “Uniform External Review” accreditation standards are available for review and comment at https://www.urac.org/publiccomment/. The deadline for public comment is August 31, 2009. After public comment, additional revisions will be made. Final draft standards are expected to be reviewed by URAC’s Board of Directors in October 2009.

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For 25 years, URAC has been the independent leader in promoting health care quality through accreditation, education, and measurement. URAC offers a wide range of quality benchmarking programs that reflect the latest changes in health care and provide a symbol of excellence for organizations to showcase their validated commitment to quality and accountability. URAC’s evidence-based measures and standards are developed through inclusive engagement with a broad range of stakeholders committed to improving the quality of health care.

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