Standards Interpretations

Case Management Version 5.0

  • CM 1: Program Description

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    The organization has a program description and/or written policies and documented procedures for case management that includes:

      (a) Clearly defined program:
        (a)(i) Objectives/goals;
        (a)(ii) Interventions relevant to the full scope of services;
        (a)(iii) Case management program performance measures;
      (b) Guidelines for establishing criteria to:
        (b)(i) Identify consumers eligible/ineligible for case management services;
        (b)(ii) Discharge and/or terminate case management services; and
        (b)(iii) Determine and adjust individual case manager caseloads;
      (c) Methodology used to measure savings attributed to case management such as return on investment (ROI); (Leading Indicator)
      (d) Where available, incorporating evidence-based, and/or clinical practice guidelines or case management guidelines for:
        (d)(i) Consumer-centered case management plans;
        (d)(ii) Clinical decision support tools; and
        (d)(iii) Health information;
      (e) Guidelines for obtaining stakeholder input for consumer-centered case management plan development involving:
        (e)(i) Consumer;
        (e)(ii) Family/caregiver(s) chosen by the consumer; and
        (e)(iii) Provider/health professionals/interdisciplinary team; and
      (f) Guidelines that clearly define the role of the case manager regarding transitions of care for determining;
        (f)(i) A consumer’s transitional care needs;
        (f)(ii) Consumer-specific interventions related to transition of care needs; and
        (f)(iii) How transitions of care needs are communicated to stakeholders (including consumers and family/caregiver(s)).

    Question: For CM Standard 1 (a (iii) the Interpretive Information states:

    CM 1(a)(iii): Organizations are expected to establish performance measures for the case management program and clearly describe them in the program description. URAC defines “performance measures” as, “qualitative or quantitative indicators for assessing the achievement of outcomes.” Do program performance measurements/metrics related to Complaints, Satisfaction and Access meet the intent of the standard/element? Must an organization also have CM Program measures related to clinical outcomes?

    Response: To comply with CM 1 (a)(iii) Case Management programs are required to establish and monitor clinical performance measures. The current version of the Accreditation Guide for CM v 5.0 states in the Interpretive Information the following specific guidance: "Organizations are expected to establish performance measures for the case management program and clearly describe them in the program description. URAC defines “performance measures” as, “qualitative or quantitative indicators for assessing the achievement of outcomes. Guidelines for case management may include nationally recognized standards for case management practice and mandated (local, state, and federal) regulations. It is essential for clinical performance measures to be bench-marked against evidence-based guidelines or clinical practice guidelines where applicable. For clinical program outcomes, organizations must establish a process to modify program interventions when there is a significant change in evidence-based or clinical practice guidelines. The program director, clinical staff and content experts should be involved with addressing any changes impacting clinical guidelines. Program performance measures may also include monitoring cost-effectiveness such as improvements in overall financial outcomes. Please note that some organizations have identified financial outcome measures that are contractually determined." So, complaints, satisfaction, and access measures do not satisfy this requirement. 

  • CM 9: Case Manager Competencies

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    The organization facilitates education for case managers to promote expertise and proficiency to remain current in case management practice. Such education includes:

      (a) Information specific to support case management practice that address:
        (a)(i) Nationally recognized standards for case management practice;
        (a)(ii) Cultural and linguistic competence for the populations served;
        (a)(iii) Ethical code of conduct; and
        (a)(iv) Community resource research skills;
      (b) Access to information and requirements specific to the benefits program, clinical and payer populations served to include the following, if applicable:
        (b)(i) Dual eligibility;
        (b)(ii) Commercial plans;
        (b)(iii) Public programs (such as Medicare and Medicaid); and
        (b)(iv) Workers’ compensation; and
      (c) Identification and reporting of incidents and/or unusual occurrences such as domestic violence, neglect, abuse and/or behavioral health issues to the appropriate entity.

    Question: Is there anything written in your Competencies or otherwise that states a Nurse Case Manager is to act as the patient advocate in Worker Comp cases?

    Response: The Accreditation Guide for Case management, v 5.0 in introductory sections includes the following information re: applicability of the standards to workers compensation. "The role of the case manager is to establish a relationship with the injured person and to educate and empower them to make sound decisions about their healthcare, with a main focus on returning to work." There also are listings of URAC CM standards that are not applicable and others that may be not applicable when the worker has legal representation. The CM advocacy role is discussed in interpreting CM 1, 7, and 9. URAC recognizes that CM 7 re: consumer education may be not applicable when communication is prohibited and that the advocacy role may be compromised in workers' compensation. These types of compromised cases are considered outside the scope of URACs case management accreditation.

  • CM 10: Case Management Staff

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    The organization establishes documented procedures to ensure that:

      (a) Case management support staff (clinical staff and non-clinical administrative staff):
        (a)(i) Have clearly defined roles and responsibilities;
        (a)(ii) Have training appropriate to defined roles and responsibilities;
        (a)(iii) If they are non-clinical administrative staff, then they are restricted from performing clinical activities; and
        (a)(iv) Have immediate access to a case manager or clinical supervisor;
      (b) The case manager:
        (b)(i) Will retain accountability for the case management plan and process; and
        (b)(ii) If interacting directly with support staff, provides input on the performance of support staff to their supervisor;
      (c) The case manager, when providing on-site/field case management services will:
        (c)(i) Carry a picture ID with full name and name of the organization/company; and
        (c)(ii) Follow applicable hospital/facility procedures, to include checking in with designated hospital/facility personnel; and
      (d) Case management staff is required to provide their name, role and responsibility regarding the case management program for identification purposes during consumer interactions.

    Question: A bullet in the interpretive guidelines indicates that an LVN/LPN cannot fulfill the role of a case manager given with requirements of a case manager (agree). It then goes on to say that an LVN/LPN cannot conduct any component of the clinical assessment including collection information using scripts or templates. According to the State Board of Vocational Nursing in California it is within the scope of practice of an LVP/LVN to do basic assessment (data collection only) by filling out a form. It is not within the scope of their practice to synthesize and develop the plan of care but they are allowed to collect information. It is difficult to tell whether this is a URAC more stringent rule that would supersede the California law or not. 

    Response: This is one of many inquiries submitted on the same standard, CM 10. The URAC standard is more rigorous than the state law. Therefore, URAC expects compliance with the standard to supersede the state law. 

    Question: Another bullet under CM 10 indicates non-case managers may not make clinical decisions (agree that it the scope of the case manager). Functions assigned to non-case managers are supported and monitored by the case manager. It is not clear what a non-case manager care support person can do since they are not allowed to collect any assessment data by filling out a form or template according to URAC.

    Response: Interpretive Information for CM 10 in the current Accreditation Guide for CM v 5.0 states in bullet # 7: "Once the case manager conducts an assessment and creates a care plan, non-clinical administrative support staff can carry out delegated duties such as: Outbound administrative calls for purposes of requesting a copy of the medical record and scheduling (to verify next appointments, attendance at previous appointments, etc.); Faxing materials; Mailing/e-mailing already identified education materials; Scheduling delivery of already negotiated and approved DME; Facilitating claims adjudication". LVNs/LPNs may perform the functions of non-clinical staff according to URAC standards.

    Question: Interpretive information for CM 10 says: Non-clinical staff cannot use scripts or populate clinical data fields in template forms to collect clinical/medical data. Case managers are responsible for the CM process and plan of care and collect this data as part of their assessment. Once the case manager conducts an assessment and creates a care plan, non- clinical administrative support staff can carry out delegated duties. The duties listed are clear, however, the next bullet says that non-clinical administrative staff may conduct follow-up or “monitoring: where the consumer, family and/or caregiver reports on the consumer’s self-management plan (not to include the collection of clinical data) (e.g. reports weight as increasing/decreasing, taking medications as ordered, keeping appointments, knows when to seek medical treatment. What is the difference between assessment and follow-up monitoring? If an LVN cannot fill out a data collection form, how can a non-clinical person conduct follow-up monitoring? The next bullet indicates that non-clinical staff cannot be the “eyes and ears” for the case manager when the consumer is under case management, however, the previous bullet indicated non-clinical staff can conduct “monitoring” of self-management activities (not clinical data) The scope of case management does not allow for non-case managers to conduct assessment activities. Are you only referring to what is listed in CM 12? What is an assessment activity?

    Response: Assessment activities are listed in CM 12 & 13. Assessment is generally understood to mean the gathering and evaluation of data that leads to development of a plan. Under URAC standards such activities are limited to those whose scope of licensure includes all of the above. For example, RNs, Social Workers (for behavioral health - not medical - assessments), and physicians. 

    Question: Included in the “Points to Remember” for CM 10 it indicates that other clinical staff and/or non-clinical staff may support the case management process and must have clearly defined roles but it is not clear from reading the interpretation what the care support staff such as an LVN/LPN can and cannot do in the support role. Wouldn’t it be clearer for URAC just to indicate that LVN/LPNs must practice within the scope of their license in a care support role?

    Response: Yes, LVNs/LPNs are expected to perform only those functions within the scope of their licensure for regulatory compliance (see Core 4). However, URAC standards explicitly prohibit LVNs/LPNs from performing any part of the assessment process. We have discussed this internally at URAC and do not believe that there is support for reconsideration of this standard.

    Question: RE: CM 10(c)(i), must the nurses’ complete first and last name be used if there is risk to staff for doing so? For example, if the nurses interview members in the community is high risk neighborhoods or are working with mentally ill, potentially violent members, must they disclose their full name. If not, what other disclosure method may be used?

    Response: Case Managers should be protected from harm. The Interpretive Information for CM 10 in the current version of the Accreditation Guide for Case Management v 5.0 states an explicit exception: "CM 10 (d): Some organizations may only permit employees to disclose their first name and company name during telephonic and/or web-based communications for safety reasons". The "company" referred to in the Guide means the accredited organization's client or a facility. So, your organization’s written policy and procedure re: first name only identification when the circumstances of disclosure include a potential safety hazard to the case manager should clearly define the circumstances warranting variation from the standard. 

  • CM 11: Case Manager Qualifications

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    The case manager position requires:

      (a) A current, unrestricted license or certification to practice a health or human services discipline in a state or territory of the United States that allows the health professional to independently conduct an assessment as permitted within the scope of practice of the discipline; or
      (b) In the case of an individual in a state that does not require licensure or certification, the individual must have a baccalaureate or graduate degree in social work, or another health or human services field that promotes the physical, psychosocial, and/or vocational well-being of the persons being served, that requires:
        (b)(i) A degree from an institution that is fully accredited by a nationally recognized educational accreditation organization;
        (b)(ii) The individual must have completed a supervised field experience, in case management, health, or behavioral health as part of the degree requirements; and
        (b)(iii) URAC-recognized certification in case management within four years of hire as a case manager;
      (c) Two years full-time equivalent providing direct clinical care to the consumer; and (d) If directly supervising the case management process, achieves URAC-recognized certification in case management within three (3) years of directly supervising the case management process.

    Question: Your list of acceptable certifications includes CMC. Their web site and telephone number are no longer valid. There is no way to verify that an individual's certification is still valid, other than obtaining a copy of the individual's original copy of the certification. Are you still accepting CMC as a valid certification and if so what will you require for verification?

    Response: URAC will accept a copy of the certificate until its expiration date as long as the listing is maintained on the URAC website. We will investigate further and sets date to sunset the listing 2 years after the latest certification issue date.

    Question: CM 11 (c) requires 2 years full-time equivalent providing direct clinical care to the consumer. If a potential CM candidate was a nurse tech before she obtained her RN, would that count toward meeting the 2 year full-time equivalent?

    Response: No, CM 11(c) is correctly interpreted that prior direct clinical care to the consumer should be at the RN level of practice. This is so that the applicant has an adequate clinical background for assessment and care planning. Such background can only be obtained via RN practice.

  • CM 12: Assessment Categories

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    The organization implements written policies and/or documented procedures requiring case managers to conduct an assessment of each consumer. During the initial or subsequent assessments, for each consumer, the case manager assesses and documents: (No Weight)

      (a) Current health status; (3)
      (b) Clinical history, including medications; (3)
      (c) Treatment plan; (3)
      (d) Resources required to meet immediate needs for health care; (3)
      (e) Care coordination needs, including transitions of care; (3)
      (f) Safety concerns; (3)
      (g) Behavioral health status, including psychosocial aspects; (3)
      (h) Social service and support needs; (3)
      (i) Consumer’s input, including perception of needs such as health care needs and social services and supports; and (Mandatory)
      (j) The need for culturally and linguistically appropriate services reflecting individual needs, if applicable. (2)

    Question: Can you clarify how factor (h) assessing/documenting social service and support needs differs from factor (i) assessing/documenting consumer's input, including perception of needs such as health care needs and social services and supports? These seem duplicative to me. What is URAC looking for specific to documentation in an assessment for each of these factors?

    Response: CM 12 (h) may not include consumer perception - rather it is an objective assessment of needs and gaps; please note that the current version of the Accreditation Guide for CM v 5.0 states: "Social service and support needs refer to a wide range of services (i.e. benefits, programs, amenities etc.) provided by public and/or private organizations intended to assist consumers with exceptional needs. Social service and support needs (see CM 15(a)(iii)) are also intended to assist consumers with independent living skills and/or community living goals and barriers." CM 12 (i) is about the consumer's perceived needs; the Guide states: "As part of the assessment, the organizations policy should address the process for case manager’s to facilitate and document input from the consumer. The consumer’s perception of their healthcare needs is intended to provide the case manager with valuable insight for care planning such as gaps in care, consumer priorities and the need for social services and support." Thus, element (h) is about objective data and element (i) refers to subjective data.

    Question: The software tool we have allows enrollment into a clinical program, for instance multiple sclerosis (MS), we are able to complete a comprehensive assessment covering all aspects of CM 12 within this program questionnaire, however, when a consumer has additional condition, we are able to open other program, let’s say joint replacement, if we consider the MS program the primary program (It was opened first), and during the enrollment period (say from 1/1/13 – 6/1/13) we open another Program for joint replacement (opened from 2/1/13 – 4/1/13), would the standard CM12 be met if we are able to show the complete assessment within the primary program, MS, and additional joint replacement assessment questions would be found in the Joint Replacement Program. We are trying to cut down duplicative work, and in this instance the assessment was conducted, but is accessible in only one of the programs.

    Response: Yes, your plan for use of your software for assessment documentation would be in compliance with CM 12. We suggest several things to assure that your documentation is clear. (1) If you use the initial condition as the "primary" one for the case, then note the others as "co-morbidities" [see Interpretive Information for CM 12 (b)]. (2) Include a note in the secondary diagnosis/co-morbidity program to state that the full assessment is documented in the program for the primary condition and that this condition is a co-morbidity. A limited assessment pertinent to the secondary condition must be documented. (3) Assure that the log you present to your URAC reviewer is driven by the primary conditions. These steps should provide a clear documentation trail to comply with CM 12.

  • CM 13: Medication Safety Assessment

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    As part of the case management assessment, the organization promotes medication safety whereby, the clinician educates, assesses, and documents the consumer, family and/or caregiver’s:

      (a) Understanding (knowledge) of current medications;
      (b) Use (adherence) of current medications, including experienced side effects;
      (c) Access to and use of current medication list (paper or electronic);
      (d) Sharing of current medication list with treating provider(s);
      (e) Need for medication reconciliation; and
      (f) Need for medication therapy management services.

    Question: This Plan’s Case Management program serves members who are at home. When an enrolled member moves from home to a medical facility, the member remains enrolled in Case Management but the care is transferred to the concurrent review nurses who are not part of the Case Management team. The Case Manager assumes care upon discharge to home. 

    The Plan has questions concerning Medication Safety - specifically points 3 and 4:
    ‘The definition of "medication reconciliation" calls for a process of creating the most accurate list possible of all medications a patient is taking "...at all transition points." To that end, the case manager must document the need for this reconciliation at the following transition points:
    • Enrollment into the case management program;
    • When the consumer is transferred to another case manager within the organization or to a case management group external to the organization;
    • Movement from one level of care to another;
    • Changes in care setting;
    • Changes in the consumer's medication-taking behavior; and
    • Transition from one lead clinician or clinical care team to another.'

    Although the member remains in Case Management, the Case Managers have passed the care to the concurrent review team are not interacting with the member. Do points 3 and 4 need to be met by Case Management even though they are not interacting with the member while in hospital, SNF or rehab facility?

    Response: Yes, the situation described in your inquiry is within the scope of CM 13. Your situation is aligned with bullet points in the Points to Remember section of the current Accreditation Guide for CM 13, including "when the consumer is transferred to another case manager within the organization or to a case management group external to the organization" and "changes in care setting". Remember that the case manager is not required to perform medication reconciliation, but rather to see that the need is communicated to a responsible party who will complete it. This is true even though the case management transfer is not technically to another case manager, the standard applies. Either your case managers or the concurrent review team should assure that medication reconciliation is done by the receiving facility. If your case managers depend on the concurrent review team, then documentation in the case file should provide evidence of the hand-off to that team member.

  • CM 14: Consumer-Centered Case Management Plan

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    The organization implements a collaborative process for developing consumer-centered plans such that written policies and/or documented procedures require that every case management plan:

      (a) Is facilitated and documented by a case manager:
        (a)(i) In collaboration with the consumer and/or individual(s) chosen by the consumer, and members of the health care team;
        (a)(ii) As needed in consultation with health professionals with expertise in the areas addressed by the consumer-centered case management plan; and
        (a)(iii) Who periodically updates the consumer-centered case management plan based upon changes in the consumer's needs; and
      (b) Identifies:
        (b)(i) Measurable short term goals;
        (b)(ii) Measurable long term goals;
        (b)(iii) Interventions with timelines to meet short and long term goals;
        (b)(iv) Resources to be utilized;
        (b)(v) Time frames for re-evaluation and response to services (follow up); and
        (b)(vi) Collaborative approaches to be used for the purpose of facilitating the case management plan as well as the coordination and transitioning of care (including family, caregiver, physician and other health care provider participation).

    Question: Problems on care plan - do they have to be nursing diagnosis phrased problems with then consumer goals and then CM interventions or can problems be simply a statement of what problem is if that is clearest way to identify - 

    Response: CM 14 does not require the use of nursing diagnosis. Problem statements in accredited case management programs take many forms. The case management plan compliant with URAC Case Management, Version 5.0 standards does require both short and long term measurable goals, interventions, resources to be utilized, and collaborative approaches as stated in element (b)(i-vi).

    Question: In setting short term/long term goals.If a short term goal is set for 30 days, and it is met in 30 days, does a new short term goal need developed to carry the entire case thru to the long term goal and resolution. Should there always be a short term goal in place?

    Response: During onsite visits when URAC reviewers audit case file documentation, it is important that there be evidence of the short term goal established per CM 14(b)(i). However, that goal also should be periodically updated per CM 14(a)(iii). So, it is not necessary that the short term goal be replaced when the time frame is extended and it becomes long term by your definition. In order to demonstrate compliance with CM 14(b)(i) and (ii), it is wise to establish a practice of opening both short and long term goals on every case that are captured in your documentation system. However, that said, it is not required to have short term goals open at all times on every case. 

  • CM 15: Care Coordination

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    As part of the case management process, the organizationestablishes written policies and/or documented procedures that address timely and appropriate coordination of services and supports for consumers. In order to facilitate these activities, the organization will assess the need for: (No Weight)

      (a) Coordination of follow up services for evaluation and management, including referrals for: (No Weight)
        (a)(i) Health care services; (3)
        (a)(ii) Behavioral health care services; (3)
        (a)(iii) Social services and supports;(3)
        (a)(iv) Providers; and (3)
      (b) Locating available community resources, including vendors to assist with consumer-identified and health care-related issues. (3)

    Question: The standard indicates that the organization establishes written policies and/or documented procedures that address timely and appropriate coordination of services and supports for consumers. With regard to establishing a measurable timeframe definition, is it acceptable to indicate something like "as mutually agreed upon by the consumer?" Also, please confirm that for the Evidence for Meeting the Standard - Onsite Review Materials and Activities...URAC will review our quality meeting minutes for evidence that we shared information specific to monitoring of timely and appropriate care coordination, and provider and/or vendor issues.

    Any additional guidance that you can share regarding the requirements of this standard is greatly appreciated.

    Response: The Accreditation Guide for Case Management, Version 5.0 CM 15 states in the Interpretive Information the specific interpretation of the standard for measurable time frame: "URAC does not prescribe the definition of "timely" but expects that the applicant organization will do so in specific measurable terms, such as calendar days or business days". A policy that does not define "timely" in terms such as calendar or business days will not be judged compliant with the standard. Remember that the stem of the standard is about the timely assessment of needs related to the areas listed in the elements and sub-elements and follow-up for identified needs with referrals for services and supports. The standard does speak to collaboration with the consumer, however, so inclusion of the phrase "as mutually agreed upon by the consumer" is a good idea. It is possible that an organization would establish different time frames for assessment and various types of follow-up. The Evidence list clarifies URAC's expectation that Case Manager performance relative to the measures of timeliness in your policy is monitored on an ongoing basis and reported to your Quality Management Committee. 

  • CM 16: Transitions of Care Planning

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    To promote effective transitions of care, the organization implements written policies and/or documented procedures that address:

      (a) The criteria used to identify consumers eligible for transitional care services, including the situations that trigger a review and possible modification of that criteria;
      (b) A formal process to proactively identify and track transitions of care;
      (c) Where applicable, guidelines for care coordination and managing transitions of care across different:
        (b)(i) Locations/care settings;
        (b)(ii) Levels of care; and
        (b)(iii) Providers; and
      (d) Consumer engagement activities used to reinforce and achieve self-management goals, to include the consumer’s use of:
        (d)(i) Individualized health care tools; and
        (d)(ii) Personal health records.

    Question: The new Transitions of Care Designation in the 5.0 CM standards - were these meant to include strictly offsite CM firms; i.e., is it reasonable for an offsite CM firm to try to meet these? It seems of the standards and what appears to be the intent would have barriers for offsite insurance case managers who can certainly request certain things be done but are not there at the actual time of transition. Transitions of care have always been incorporated and addressed, but it appears some of the standards/interpretations lend themselves to an onsite Case management role. Can you clarify?

    Response: First, it is important to recognize that the Transitions of Care designation standards CM 16, 17 & 18 are optional. That said, however, the standards are intended to apply to telephonic case management as well as onsite case management practice. There is much to coordinate in both the pre and post transition phases. Safe transitions are defined by URAC as those that are error free. The telephonic Case Manager can collaborate with facility or office-based Case Managers throughout the process toward the end that the patient is well prepared, has adequate knowledge and tools to participate in self-care and to follow through on continued care with the next level provider. Think about how much can be done to assure that prescriptions are filled, understood and taken properly; and/or assistance in managing follow-up appointments or unexpected needs when they arise. The intent is for there to be a continuum of case management. Please refer to the Glossary found in the Accreditation Guide for the definition of "transitional care" and give thought to the appropriate role insurance Case Managers can play in consumer engagement and safe transitions. It is not necessary that the Case Manager be on site or try to do it all, but rather that the insurance-based practice engages in the process appropriately throughout and has knowledge about the entire transitional process. We suggest taking a look at the National Transitions of Care Coalition website, http://www.ntocc.org/, for a wealth of useful information. 

    Question: For the transition of care (TOC) standards. How are you measuring the populations for meeting the standards for inclusion in the TOC standards? Meaning, do they have to be high risk or already in a CM program for inclusion? Or is it the Health Plan policy to determine which patients and how they are identified for inclusion in TOC planning? And if a member is assessed for Transition of Care, do they also require the full assessment standards criteria?

    Response: As stated in the current version of the Accreditation Guide for Case Management version 5.0 CM 16, the definition of the criteria for inclusion in transitions of care planning is set by the applicant organization. The Interpretive Information states: "this standard element is intended for organizations to develop criteria to identify which consumers are eligible for transitional care services with consistent application" and "the intent for establishing criteria is to define the rationale for what prompts the case management process to begin for managing transitions of care". The Guide goes further to provide some examples, but is clear that URAC leaves establishment of the criteria to the applicant organization. CM 12 is the Assessment standard. Interpretive Information in the Guide provide the clear interpretation that "not all items listed in the assessment categories will be pertinent to every consumer or population served". Thus, your assessment policy and procedure can limit the assessment required if the only case management service anticipated is transition of care management. It would be important to consider those categories pertinent to safe transitions in establishing your criteria. If the case turns out to need full case management, then a complete assessment would be indicated at that juncture. 

    Question: It is my understanding that CM 16-18 are optional standards. If you choose not to meet the standards or participate, and meet CM 1-15, you will receive your accreditation? If you decide to meet CM 16-18 (Transitions of Care Standards), you will receive the optional transition of care designation. What is this designation and does it appear on the certificate, etc.?

    Response: Yes, the Accreditation Guide for Case Management v 5.0 states in the Scope of Standards section for CM 16: "CM 16, CM 17 and CM 18 are optional standards to obtain a separate Transitions of Care designation". So, they are not required to receive accreditation for Case Management. Organizations that successfully comply with CM 16-18 are recognized on their Accreditation Summary Report (Certificate) for achievement of the Transitions of Care Designation. It is shown on the URAC website as well. 

  • CM-18: Transitions of Care Follow-Up

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    To ensure continuity of care and prevent facility re-admissions, the organization conducts proactive outreach to facilitate effective transitions of care. To achieve these goals, the organization implements:

      (a) A clearly defined plan for consumer:
        (a)(i) Outreach;
        (a)(ii) Goals; and
        (a)(iii) Monitoring; and
      (b) A process specific to care transitions from a facility for conducting:
        (b)(i) Initial outreach within two (2) calendar days; and
        (b)(ii) Subsequent outreach within fourteen (14) calendar days.

    Question: 1. B (i) initial outreach within 2 calendar days. Our organization is a private UM/CM organization. Referrals are made to case managers, sometimes during the patient’s inpatient say. Since we are not on site at the hospital, we may not always know the discharge date until after the discharge has occurred. How will this be handled? Does this only apply to those patients who have been reviewed and determined appropriate for CM by the case manager, as the patient is not officially opened to CM until the case manager receives consent on the initial patient consultation. In almost all cases, this initial consultation/consent does not occur until the patient is discharged. Or, does this apply to any patient, whether referred to CM or not?

    My second question, if in fact we must make an initial outreach within 2 calendar days following discharge from a facility, may be accomplished by a non-clinical staff and then the subsequent outreach conducted by the case manager at 14 calendar day? We have developed a tool for the initial outreach as attached.

    Response: CM 18 requires that Case Management organizations work with facilities from whom referred patients are commonly discharge to expedite the exchange of information at time of discharge (CM 18 a) so that follow-up will be timely (CM 18 b). Please refer to the second bullet in the interpretive information for CM 18 in the Accreditation Guide for CM v 5.0 for the expectations of the Case Management organization. Re: your second question - only if your caseload is not geographically defined and you manage patients discharging from a disparate number of facilities with which you do not have established relationships, could the case be made to follow-up within 2 days of referral. Unfortunately, our interpretations system does not forward attachments; so no review can be done via this mechanism. We suggest you look carefully at the transitions of care tasks in the Accreditation Guide to ensure that qualified personnel are engaged in the initial contact. Those tasks include completion of assessments and consumer education - both generally considered the practice of nursing.

Case Management Version 4.1

  • General Question, Standards 1-28: File Review

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    Question: We are seeking accreditation under the URAC standards for the first time.  When the Reviewer visits our offices to conduct the onsite review, what can we expect as it pertains to the date range for selecting files for review?

    Response: For organizations that are seeking initial accreditation in any given module, URAC expects the organization to have been in compliance with the standards since at least the date that the application was submitted.  Therefore, the file pull date range would be from the date of the onsite visit back to the date the application was submitted to URAC.

  • Standard 2: Case Manager Case Load

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    The organization:

    1. Establishes guidelines for reasonable case manager caseload with supporting rationale;
    2. Applies an ongoing process to monitor caseload based on guidelines developed by the organization;
    3. Consistent with the guidelines established in CM 2(a), employs/contracts with an adequate number of case management personnel to provide services to the consumers of the program; and
    4. The organization identifies those circumstances that trigger a review and possible change in its case load guidelines.

    Question: Does URAC specify what a case manager case load should be?

    Response: URAC does not specify what a case manager case load should be; however, in standard CM 2, a new element was added whereby an organization identifies those circumstances that trigger a review and possible change in its case load guidelines. Caseloads are dynamic and books of business change; therefore, caseload guidelines should be reviewed periodically.   

      

  • Standard 4: Case Manager Qualifications

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    The case manager position requires:

    1. Licensure or certification in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice of the discipline;
    2. Two years full-time equivalent of direct clinical care to the consumer; and
    3. At least one of the following:
    4. Certification as a case manager from the URAC-approved list of certifications; or
    5. A bachelors (or higher) degree in a health or human services related field; or
    6. A registered nurse (RN) license.

    Question:  I have searched the URAC Web site and cannot locate the list of URAC recognized case management certifications.  Can you please provide me with the web link?

    Response: The link to the URAC recognized case management certifications is: https://www.urac.org/wp-content/uploads/URAC_Recognized_Case_Management_Certifications.pdf.

    Question: What are the requirements for clinical experience for case managers and does it apply to just RNs?

    Response: The requirement for direct clinical care to the consumer is two (2) years and it applies to all case managers, not just those that hold an RN license.  Staff hired prior to the organization seeking and obtaining accreditation may be grandfathered in if they do not meet the minimum two (2) years of clinical experience requirement and they possess a minimum of five (5) years case management experience.
  • Standard 6: Case Manager Supervisor Qualifications

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    Individuals who directly supervise case management practices:

    1. Meet the qualifications for case manager as defined in CM 4; and
    2. If they have directly supervised the case management process for at least three (3) years with the organization, hold a certification in case management from the URAC approved list of certifications.

    Question: If a supervisor has directly supervised the case management process for three or more years in another organization and that supervisor is subsequently hired as the case management supervisor for a program that is seeking URAC accreditation does the prior supervision count, therefore requiring the supervisor to be certified as a case manager?

    Response: The CM certification requirement applies to individuals who have held the position of a case management supervisor in the applicant organization for 3 or more years. If the individual has held the position of case management supervisor in the applicant organization for less than 3 years at the time of application review, this standard is non-applicable.  

    Question: Does URAC require that case manager supervisors be certified in case management?

    Response: Yes, if the applicant organization want to achieve full points for standard CM 6 "Case Manager Supervisor Qualifications," then all supervisors must be certified in case management if they have directly supervised the case management process for at least three (3) years with the applicant organization. If the individual has held the position of case management supervisor for less than 3 years at the time of application review, this standard is non-applicable.

  • Standard 10: Case Review Process and Evaluation of Goals

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    The organization conducts reviews of the case management process through case review to promote achievement of case management goals as established in consumer-specific case management plans. These case reviews, conducted by the case management program director or other supervisor (or equivalent designate) in collaboration with the case manager, include analysis of short and long term goals to:

    1. Evaluate if goals are appropriate considering the circumstances surrounding the case and if not, revise them; and
    2. Determine if goals are being met and if not, examine why to establish next actions to move towards goal.

    Question: Our organization recently went through a downsizing leaving us with one Nurse Case Manager who is our Case Management Supervisor. As a result, the Director of Quality Assurance assumed responsibility for auditing the Nurse Case Manager claims.  Is this arrangement sufficient for purposes of meeting the intent of CM 9?  If not, do you have recommendations for meeting the intent of this standard?

    Response: It is acceptable for the Director of Quality to perform quality audits for case management.

  • Standard 15: Case Manager Ethics Training

    + Details

    The organization educates case management personnel, no less than annually, on written policies and documented procedures supporting the ethical framework for case management practice including:

    1. Advocacy for consumer needs;
    2. Guidance for professional relationships with consumers;
    3. Prohibition of relationships that could compromise professional objectivity;
    4. Resolution of conflicts of interest between the case manager, consumer, third party payer, provider or other entity;
    5. Business, financial and marketing practices;
    6. Resolution of perceived lapses in quality of care resulting from actions by consumers, payers, case managers, providers, organizations or other entities affecting the case management process;
    7. Policies that address case managers' handling of consumer needs when such needs extend beyond the scope of the organization's services;
    8. Prohibition of discrimination against a consumer or group of consumers by the case manager or organization; and
    9. Information on how policies regarding the ethical framework will be shared with staff, contractors, clients, and consumers.

    Question: May telephonic case managers conduct utilization review as part of their work?

    Response: If the Case Manager is involved in benefits determinations, safeguards should be put in place to assure that the role of advocacy is not compromised. Examples include conducting interviews and case file review.  Most organizations conduct an annual review of the organization's ethical framework for case management practice (along with review of confidentiality policies).  This annual review, which must address all sub-elements in the standard, is documented in each case manager's file or an attendance sheet is kept to document the review.  Please also contact the organization's compliance department as there may be regulatory implications.

  • Standard 19: Case Management Consent

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    The organization implements written policies and/or documented procedures regarding consumers' consent for participation in case management activities that:

    1. Require obtaining and documenting oral or written consent;
    2. Indicate the time frame in which the consent must be obtained; and
    3. Indicate the duration of the validity of the consent.

    Question: We currently obtain oral consent from individuals we are case managing. This oral consent is documented in our system.  In order to comply with standard CM 19, do we also need to make an attempt to obtain written consent? If so, does URAC have an example of a consent form?

    Response: No the organization is not required to obtain verbal consent and make an attempt at obtaining written consent.  The standard states that the organization obtains and documents a verbal or written consent. The organization must establish written guidelines for obtaining consent and may allow that consent is not obtained in every case.  If the organization allows exceptions from consent requirements, it should be prepared to justify those exceptions for quality of care, legal, or other valid reasons on a case-specific basis.  It is expected that this consent is obtained from the consumer (patient), but may be from a family member in extenuating circumstances, (e.g., patient is unconscious, a minor, or determined not legally competent).

  • Standard 23: Assessment Categories

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    For each consumer during the initial or subsequent assessments, the case manager assesses and documents:

    1. Current health status;
    2. Clinical history, including medications;
    3. Treatment plan;
    4. Medication safety, including:
    5. Medication knowledge;
    6. (ii) Medication adherence; and
    7. The need for medication reconciliation;
    8. Resources required to meet immediate needs for health care;
    9. Care coordination needs, including transitions of care;
    10. Psychosocial status; and
    11. Safety concerns.

    Question: Does URAC specify assessment categories for the assessments conducted by the case manager?

    Response: Yes, starting in version 4.0, there is a requirement to address particular areas of assessment for each consumer.  Not all categories will necessarily be assessed at the initial or subsequent case management visits. Organizational policies should provide guidance to the case manager on the assessment process and priority areas.        

  • Reporting to URAC on Mandatory Measures: RPT 1

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    The organization reports on all mandatory measures required for this accreditation.

    Question: Which version of the standards includes measures for case management?

    Response: Version 4.1.  There are two standards associated with the case management measures.  Reporting standard 1 requires that organizations have the resources and mechanisms to produce and report on a specified set of performance measures on a periodic basis.  The second reporting standard indicates that organizations will report on the measures.  There are six (6) measures where four (4) are mandatory and two (2) are optional as "exploratory" measures.   

    Question: What is necessary to have in place as evidence for having systems in place to collect CM performance measure data?

    Response: In order to demonstrate compliance with the standard, the organization should assign at least one person the responsibility for collecting, analyzing and reporting the measures.  The person's job description should address this responsibility.  The organization should also have in place a written data collection plan that identifies the performance measures including the populations and departments or programs addressed, what data is collected, what constitutes the numerator and denominator, the method(s) of calculation, and the analysis and reporting methodologies. During the onsite review, URAC reviewers will verify that the organization's data collection plan to address the measurement standards has commenced.

  • Reporting to URAC on Mandatory Measures: RPT 2

    + Details

    The organization can choose to report on any of the exploratory (leading) measures that may be included with this accreditation.

    Question: Which version of the standards includes measures for case management?

    Response: Version 4.1.  There are two standards associated with the case management measures.  Reporting standard 1 requires that organizations have the resources and mechanisms to produce and report on a specified set of performance measures on a periodic basis.  The second reporting standard indicates that organizations will report on the measures.  There are six (6) measures where four (4) are mandatory and two (2) are optional as "exploratory" measures.   

Core Version 3.0

  • General Questions

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    Question: Why were the standards in Core renumbered and will URAC provide a crosswalk for this renumbering from version 2.1 to 3.0?

    Response: For the URAC Core Organizational Quality Standards version 3.0 (Core), the standards were reorganized to ease the application process. Standards listed first apply to all health care organizations. These standards are followed by those where the applicant organization must have licensed or certified clinical staff in order to conduct the function covered by the accreditation. The last sections of Core apply to those organizations that interact directly with health care consumers on an ongoing basis in order to provide health care management support services directly to the consumer.

    A list of the accreditation programs and the standards that apply to each along with a standard numbering crosswalk from version 2.1 to 3.0 and 3.0 to 2.1 are located in the front of the accreditation guides.

    Question: Does URAC consider shredding and/or storage of records of Personal Health Information (PHI) and/or Individually Identifiable Health Information (IIHI) delegation?

    Response: Yes, shredding and/or record storage of PHI/IIHI is considered a delegated function with regulatory compliance implications. Depending on whether you provide services under worker's compensation or general health will determine what information must be provided to demonstrate compliance. A worker's compensation organization must execute a vendor contract agreement, and develop a policy and procedures that detail (where applicable) how the vendor storage receptacles are secured onsite, how the vendor receptacles IIHI are transferred to the vendor, the location where destruction is performed (onsite/offsite) how health information is transported offsite for shredding and destruction and/or storage. A Business Associate (BA) agreement is not required. However, the vendor agreement should address breach, and breach remediation. Attaching vendor policies and procedures to the vendor agreement may be helpful. For general health an organization must execute BA, and Vendor agreements that address the following elements: breach, breach remediation, transferring of data, requirements of training for the BA's workforce, and proper handling of the PHI. This may be done by attaching the business associates policies and procedures to the agreement as attachments or addressing the specific elements in the contract. The organization must also develop a policy and procedures that detail (where applicable) how the vendor storage receptacles are secured onsite, vendor receptacles containing PHI are transferred to the vendor, the location where destruction is performed (onsite/offsite) how health information is transported offsite for shredding and destruction and/or storage.

  • Standard 13: Information Management

    + Details

    The organization implements information system(s) (electronic and paper) to collect, maintain, and analyze information necessary for organizational management that:

    1. Provides for data integrity;
    2. Includes a plan for storage, maintenance and destruction; and
    3. Includes a plan for interoperability;
    4. Between internal information systems; and
    5. With external entity information systems.

    Question: For the new standard elements in Core 13 on interoperability, do we need to have implemented the plan for interoperability?  Does the plan have to be approved?  And if so, who needs to approve it?

    Response: Core 13(c) calls for a plan for interoperability, but it does not have to be implemented or approved – a comprehensive draft will meet the intent of the standard.

    The plan needs to address the information exchange between an organization's internal information systems [Core (c)(i)].  It also needs to address the information exchange between its internal information systems and those of external entities [Core (c)(ii)]. 

    As with any plan, a description of current information system structure is needed to show what is currently in place (how many systems do you have, do they need to talk to each other and if so, is that data exchange occurring as needed, etc.)  The same baseline analysis applies to the data exchange with external entities.  The plan should address the need to exchange data and the feasibility of making that occur – what resources would it take to make it happen and what are the inherent risks – both for and against – exchanging information both internally and externally? 

  • Standard 14: Business Continuity

    + Details

    The organization implements a business continuity plan for program operations, including information system(s) (electronic and paper) that:

    1. Identifies which systems and processes must be maintained and the effect an outage would have on the organization's program.
    2. Identifies how business continuity is maintained given various lengths of time information systems are not functioning or accessible;
    3. Is tested at least every two years; and
    4. Responds promptly to detected problems and takes corrective action as needed.

    Question: URAC used to have a standard requiring a "disaster recovery plan" and now it doesn't appear to be included in Core.  Was this requirement dropped?

    Response: In version 3.0, standard Core 14 on "Business Continuity" incorporates the previous concept of "disaster recovery."  The standard expands on the concept in an effort to ensure that organizations account for various levels of interruption in their business operations – will business be interrupted for 1 hour? 1 day? 2 weeks?  What's the plan for each of these scenarios?  Are both paper and electronic systems addressed in the plan?  Testing means that the alternate system was put in place and used to see how well it worked.

  • Standard 15: Information Confidentiality and Security

    + Details

    The organization provides for data confidentiality and security of its information system(s) (electronic and paper) by implementing written policies and/or documented procedures that address:

    1. Assessment of the potential risks and vulnerabilities to the confidentiality, integrity and availability of information systems;
    2. Prevention of confidentiality and security breaches; and
    3. Detection, containment and correction of confidentiality and security violations.

    Question: URAC has expanded the areas for organizations to address related to information confidentiality and security, but is the scope of the standard the same?

    Response: Core 15 addresses data confidentiality and security of both the electronic and paper information systems supporting the function covered by the accreditation.  In addition, "electronic" includes Web-based information systems and the use of portable media (e.g., portable computers, hand-held devices, flash drives, etc.)

  • Standard 19: Quality Management Program Requirements

    + Details

    The organization has a written description for its quality management program that:

    1. Is approved by the organization's appropriate oversight authority; 
    2. Defines the scope, objectives, activities, and structure of the quality management program;
    3. Is reviewed and updated by the Quality Management Committee at least annually;
    4. Defines the roles and responsibilities of the Quality Management Committee; and
    5. Designates a member of senior management with the authority and responsibility for the overall operation of the quality management program and who serves on the Quality Management Committee.

    Question: Does an organization's Board of Directors have to approve its quality management program?

    Response: It can, but it does not have to.  Core 19(a) was revised to broaden the types of acceptable entities that can approve an organization's quality management program description such that "governing body" was replaced with ""…appropriate oversight authority."  This was done to address those situations where a board of directors is not the appropriate oversight authority for the quality management program.  An oversight authority reviews and approves the program description and has the knowledge and power to ensure that the resources are available to carry out the goals set for the quality management program.

  • Standard 27: Staff Training Program

    + Details

    The organization has an ongoing training program that includes:

    1. Initial orientation and/or training for all staff before assuming assigned roles and responsibilities;
    2. Training in current URAC Standards as appropriate to job functions;
    3. Conflict of interest;
    4. Confidentiality;
    5. Documentation of all training provided for staff; and
    6. Ongoing training, at a minimum annually, to maintain professional competency.

    Question: There used to be a standard element (g) in Core 7 (version 2.1) that required staff training in fraud, waste and abuse.  Do the standards still require training in this area?

    Response: Fraud, waste and abuse issues are addressed through state and federal regulation and as such are covered as part of an organization's compliance program, which is within the scope of the regulatory compliance standard (Core 4 in version 3.0).  Training in these areas would be conducted as needed to ensure the organization's compliance with applicable laws and regulations [see Core 4(b)].

  • Standard 32: Senior Clinical Staff Responsibilities

    + Details

    A senior clinical staff person's program responsibilities include:

    1. Provides guidance for clinical operational aspects of program;
    2. Is responsible for oversight of clinical decision-making aspects of program;
    3. Has periodic consultation with practitioners in the field; and 
    4. Ensures the organizational objective to have qualified clinicians accountable to the organization for decisions affecting consumers. 

    Question: What is the purpose of adding element (d) to Core 32 related to senior clinical staff responsibilities?

    Response: Element (d) was added to address an important component of the senior clinical staff person's role.  Since the senior clinical staff person may or may not serve as a clinical decision-maker for the clinical areas covered by the organization's services, the new standard element makes it clear that it is part of this person's responsibility to make sure that the organization has qualified clinicians accountable to the organization for decisions affecting consumers.  By way of example, if the CMO for a health plan is a pediatrician, then for those clinical issues that pertain to internal medicine this CMO would make sure that a clinician with the appropriate clinical background and experience in internal medicine is available to make decisions in this area.

  • Standard 35: Consumer Complaint Process

    + Details

    The organization maintains a formal process to address consumer complaints that includes: 

    1. Process to receive and respond in a timely manner to complaints;
    2. Notice (written or verbal) of final result with an explanation; 
    3. Informs consumers of the avenues to seek further review if an additional complaint review process is available;
    4. Evidence of meeting the organization's specified time frame for resolution and response; and
    5. Reporting analysis of the complaints to the quality management committee.

    Question: What type of evidence is referred to in Core 35(d)?

    Response: URAC review staff will look for reports showing summary data on complaints and an analysis of the organization's average response time as compared to the timeline it has set for resolving and responding to complaints.  During the onsite review, complaint records will be reviewed and more granular reporting analyzed against summary reports. Staff and management will be interviewed to verify their understanding of the complaint process, the organization's specified time frame for a response, and that an analysis of the complaints is forwarded to the quality management committee.

  • Standard 36: Coordination with External Entities

    + Details

    The organization establishes and implements mechanisms to promote collaboration and communication with applicable external entities to coordinate health services for consumers.
    Question: What is URAC going to look at with respect to compliance with this standard on coordination with external entities?  What happens if our organization reaches out to coordinate with others and they don't respond – will their lack of response be held against us in the application?

    Response: The intent of Core 36 "Coordination with External Entities" is for organizations to establish processes to promote cooperation and effective communication with other organizations in the interest of safe, quality health care.  That being said, applicants will not be penalized for things they do not control, which includes the situation where external entities do not communicate back to you.
    As for verification of compliance, on the desktop review, reviewers will look to see written policies and documented procedures (e.g., process flowcharts, guidelines, etc.) reflecting the organization's process for sharing information and coordinating care for a health care consumer.  During the onsite review, staff will be interviewed and asked to discuss current procedure for care coordination and discuss instances where these procedures were implemented.  Case documentation exemplifying care coordination with external entities will also be examined. Applicants will be asked to pull cases illustrating implementation of its care coordination policy.  The scope of this standard covers coordination of the provision of clinical services to consumers.

  • Standard 40: Health Literacy

    + Details

    The organization will implement a documented practice addressing health literacy that:

    1. Requires consumer materials to be in plain language.
    2. Assesses the use of plain language in consumer documents; and
    3. Provides relevant information and guidance to staff that interfaces directly with, or writes content for, consumers.

    Question: We have certain documents, such as letters to the consumer that have to include specific language as required by law.  How will URAC handle this given that much of it is not in plain language and may even include legal terms that many cannot understand?

    Response: Organizations are not expected to change those documents or sections of documents that must be written with specific language due to federal or state law; however, where changes can be made and content is under the organization's control, the organization uses plain language to communicate with the consumer.  Please note that "health literacy" and "plain language" are defined terms.

Disease Management Version 4.0

  • DM 1: Disease Management Program

    + Details

    The disease management program establishes and implements policies and procedures that at a minimum address:

      (a) The scope of disease management services for each clinical condition, including relevant comorbidities
      (b) Health care disparities;
      (c) How the disease management program works collaboratively with providers to promote medical and scientific evidence and clinical practice guidelines for individual conditions as well as comorbidities
      (d) How the disease management program promotes consumer engagement, consumer self-management and informed medical decision-making;
      (e) How the disease management program handles care coordination and transitions along the continuum of care;
      (f) How the disease management program evaluates and measures its processes and outcomes; and
      (g) How the disease management program provides services to the consumer, family and/or caregiver.

    Question: We are discussion on how to present the documents for the On-Site visit. Is there a preferred way URAC wants to review the material? Can you please clarify what you mean by "flagging" the material? Does the flagging need be on the individual document or can we have a document that cross references the location.

    Response: Documents can be reviewed electronically or on paper; it is not necessary to print things for URAC review if yours is an electronic document company. That said, electronic reviews usually require someone from the organization's staff to "drive" and show things to the reviewer when requested. Some organizations create binders or folders to organize printed documents, but that is not a requirement. Creating a cross-walk for your reference is a helpful thing to do so you know what goes with which standard and have something to refer to during the onsite. URAC reviewers are flexible re: how you present your documents; do what will work best for you. Flagging can be done by post it tabs (for example) or any other visual method of pointing the reviewer where to look. For example, if looking for the approval date of QIPs in minutes of the Quality Committee, it saves a lot of time if the page(s) and paragraphs are marked. Hunting for such things during your onsite often is stressful - more so for organization staff than the reviewer. You may use a cross reference guide if you wish, but we suggest then that someone be prepared to assist the reviewer with locating the actual documents and that you have things really well-organized. We also suggest that you pay close attention to the evidence list for onsite for each standard in the Accreditation Guide to know what will be examined during onsite.

    Question: Our Clients give us information on other benefits/services available to their members/consumers. This we refer to as "Cross Referrals". In implementation the client will inform us what we can share with their members/consumer. We do not call/speak with the "cross referral" we just offer the service of: giving a number. email address and sometimes a contract name.   Group Vision Service and Case Management Referral. The question is: By doing this service is this part of Standard Core 36 = Coordination with External Entities?

    Response: The current version of the Accreditation Guide for Core 36 in Disease Management v 4.0 states in the Interpretive Information that: "this standard is not applicable if the organization’s contracts with clients do not allow coordination of consumer health services with external entities". In your inquiry, it sounds like your client limits what you can do to coordinate with external entities, but that you are doing what is permitted. Therefore, Core 36 is applicable to the limits established by your client contract. If the contract language is not specifically limiting, we suggest that you have some type of signed letter or MOU contract attachment that addresses the clients limitations on collaboration with other entities.

    Question: We have delegated vendors who conduct our Lab Test and compile the results. They deal with the consumer directly and the data they collect is forward to the client. We speak with vendor continuously. Regarding the consumer we give information on how to reach or location of the vendor - in the form of marketing material and on the phone. Again, By doing this service is this part of Standard Core 36?

    Response: Yes, collaboration with your lab service is consistent with the intent of Core 36.

    Question: I am in need of some clarification. Are there any specific standards that refer to an “Employee Handbook” or reference to what employees should receive upon hire. This would not include policies or procedures, but general employment information.

    Response: URAC standards are silent regarding the contents of Employee Handbooks. Core 27 does include a listing of required training for employees within the scope of the accreditation application. Many organizations include content in their Employee Handbook to comply with requirements for training on conflict of interest, confidentiality (HIPAA and HITECH), and other pertinent regulatory requirements (e.g. fraud, waste and abuse).

    Question: We currently hold Disease Management Accreditation for our Adult Diabetes Management Program. We are considering adding a level of stratification for this program that would make available added interventions for a subset of the currently eligible Adult Diabetes population, based on specific eligibility criteria for the new level. Given no other changes to our program and policies, would this be considered a material change in our accreditation, requiring a Change Notification form?

    Response: This would, indeed, require notification through an Organizational Change Form submission, as the scope of accreditation is impacted by the contemplated change. As a result of the notification, URAC would ensure that the currently cited Disease Management conditions covered under the scope of accreditation are still accurately reflective of your operations, while re-stratifying them as necessary to indicate the sub-set of interventions to be offered under the new program that you anticipate establishing. Such notice must be made within thirty (30) calendar days of new program implementation.

    Question: I have been asked the question is there any URAC Guidelines on what should be included in the Handbook? Do you how I can find this information?

    Response: URAC standards are silent on the contents of an Employee Handbook. However, many organizations do use their employee handbook content to address parts of Core 27, which includes (in part): "The organization has an ongoing training program that includes: "... (c) Conflict of interest; (d) Confidentiality [of PHI/IIHI]". For more specifics re: confidentiality requirements, see Core 16 Confidentiality of Individually-Identifiable Health Information. Staff also are expected to know about your quality management program [see Core 21 (g)] and the availability of policies and procedures related to their job [see Core 28]. Such topics could be included in an Employee Handbook, but that is not specifically required by URAC. The URAC requirement is that employee have the information and receive required training.

  • DM 4: Communication with Treating Providers

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    The disease management program establishes and implements procedures for communicating with treating providers and their representatives in a collaborative manner to promote quality of care and care coordination for participating and/or eligible consumers that include:

      (a) Developing policies that specify when the disease management program will refer consumers’ clinical questions to treating providers;
      (b) Defining the circumstances under which the disease management program will initiate communications with treating providers, including scheduled and non-scheduled communications;
      (c) Communicating the disease management care plan and key areas that need provider support, including provider intervention for medication reconciliation;
      (d) Identifying and communicating with additional provider(s) who treat the consumer’s other chronic condition(s) or comorbidities, when appropriate (per the disease management program’s policy), to address gaps in care and enhance team-based coordinated care and communication; and
      (e) Information on rights and responsibilities of providers whose patients are participating in the disease management program.

    Question: Our policy states that we will communicate with a member's PCP after initial assessment, at f/u calls based on need, and at program complete. If a member does not want us to send summaries or correspond with their physician, do we disenroll them or can we document that on the demographics screen and still keep them enrolled in the program? Please advise.

    Response: URAC DM standards address both communication with treating providers and member rights and responsibilities. DM 17 re: Participating Consumer Rights and Responsibilities includes element (f) the right to decline to participate and element (i) the responsibility to notify their treating provider of their participation in the DM program. Taken together, these standards provide an answer to your inquiry: that is, that the member should not be disenrolled if they wish to continue to participate and the member should then be responsible for notifying their provider. As you suggest, this should be documented in the case file. The record should include the consumer's direction not to communicate with the treating provider(s) and their understanding that it is their responsibility to communicate their participation in the DM program to their provider(s).

    DM 4 requires that an accredited organization define when contact will be made with providers. However, it is silent on the member's rights to prohibit communication with their provider(s).

  • DM 6: Disease Management Program Staffing

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    The disease management program defines the allowable scope of activities for licensed or certified clinical staff and non-licensed or non-certified non-clinical staff in carrying out its disease management activities that:

      (a) Is consistent with standards of practice for licensed or certified personnel;
      (b) If applicable, allows non-clinical staff to conduct intake, non-clinical data collection, and scripted clinical data collection using appropriate documented instructions and scripts;
      (c) Prohibits non-clinical staff from conducting evaluation or interpretation of individual clinical data; and
      (d) Provides for supervision of non-clinical staff in the disease management program by licensed or certified staff.

    Question: Can an LPN outreach coordinator be used to gather responses to a scripted assessment. In addition can a non-clinical outreach coordinator gather the same responses to a scripted assessment form. No decision making is to be made, only data collection.

    Response: The answer to your inquiry is in part contained in the standard itself and partially in state laws and regulations. Whether or not an LPN can gather scripted clinical data is not addressed in DM 6 except in element (a) which requires adherence to state scope of practice laws. In most states LPNs may collect clinical data, but are not permitted to assess or evaluate that data (they are expected to report it). We suggest you consult with the state laws and regulations applicable in the jurisdictions in which you do business for guidance re: LPN scope of practice limits. The standard is very specific, however, about the limitations on the role of non-clinical personnel. DM 6(b) and (c) clearly state that nonclinical staff may collect scripted (or algorithmic) clinical data; element (c) prohibits nonclinical staff from any form of interpretation of clinical data. Of course, nonclinical staff may collect and enter such information as member demographics and eligibility.

  • DM 9: Measuring Program Performance by Clinical Condition / DM 14 – DM Reporting on DM Outcomes

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    The disease management program measures program performance and effectiveness for each clinical condition in a manner that reflects current medical or scientific evidence or clinical practice guidelines:

      (a) Establishing clinical process(es) and outcome objectives for each condition;
      (b) Evaluating key work processes used to impact overall program delivery;
      (c) Measuring at least two outcomes, one of which is clinical and one of which addresses utilization indicators for each condition targeted based on objectives established for that condition; and
      (d) Comparing performance data to program outcome goals.

    Question: Both of these standards require 2 outcomes. We understand that the subjective outcome in DM 14 (quality of life or care experience) is unique, but how is the objective outcome required in DM 14 different from the 2 outcomes required in DM 9, or is there overlap?

    Response: DM 9 - DM 9 and DM 14 may in fact be related. DM 14 requires an annual report on at least one condition, as stated in the Scope of the Standards section of the current version of the Accreditation Guide. DM 9 requires both process and outcome measures (see elements a & b). DM 9(c) directs that there be two outcome measures: one clinical and one related to utilization. These data can be used to meet DM 14(a) if there is a report generated on at least an annual basis. Note, however, that nothing in the standards prohibits an organization from addressing DM 9 and DM 14 using separate measures.

  • DM 19: Stratification of Eligible Consumers

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    The disease management program implements a process for stratifying a population of eligible consumers into groups that:

      (a) Defines criteria for each level of stratification and identifies at which levels eligible consumers will receive an individual assessment;
      (b) Is based on written criteria that define data sources for conducting the stratification and assessment processes;
      (c) Includes an initial stratification of eligible consumers that can be used to prioritize contact with consumers;
      (d) Is conducted according to timelines that require the disease management program to complete the stratification and assessment processes within a specified period of time after identification of eligible consumers;
      (e) Ensures that as they are identified, co-morbid conditions and risk factors are documented and considered in the assignment of stratification levels and interventions; and
      (f) Includes periodic evaluation for re-stratification or re-assessment, which must be conducted at least annually.

    Question: Are audits for nurses and enrollment specialist on the new standards required to be completed by on-site visit?

    Response: No, it is not necessary for your staff audits of compliance with DM 19 procedures to be completed prior to your onsite visit. As I said when we spoke on the phone, you should be prepared with evidence of a well-developed plan, however. It would be a bright idea for your plan to include specific audit procedures.

    Question: For onsite, c and d standard states "review of tracking system to verify compliance with timelines for completing the process and conducting reassessment or re-stratification" and that consumers are contacted in a timely manner after initial ID according to program criteria" Our question: is this review on an individual level with case audit or do we need to have a report measuring the entire DM population?

    Response: The case file audit tool for DM v 4.0 includes DM 19 (a), (d) & (e). In addition, DM 19 is evaluated via reports. It would be important that the reports produced for your onsite contain the following: evidence of the application of the criteria defined in your written description of stratification levels; timeliness of completion of stratification in accordance with your policies and procedures; the inclusion of co-morbid conditions and risk factors in the stratification determination; and the link between stratification and assessment. All are required during the onsite to show compliance with DM 19. Multiple documents may be produced to assure that you meet all of these requirements.

  • DM 21: Assessment Categories

    + Details

    For each assessment category during the initial or subsequent assessments, clinical staff assesses and documents:

      (a) Current clinical condition, including:
        (i) Chronic conditions;
        (ii) Comorbidities; and
        (iii) Risk factors;
      (b) Current functional health status;
      (c) Clinical history, including medications;
      (d) Psychological and social status, including family and caregiver situation;
      (e) Obstacles to care, including:
        (i) Access to care;
        (ii) Financial constraints; and
        (iii) Inadequate caregiver support;
      (f) Medication management, including:
        (i) Medication knowledge;
        (ii) Medication adherence; and
        (iii) The need for medication reconciliation;
      (g) Care coordination needs, including transitions of care;
      (h) Gaps in care;
      (i) Level of health literacy;
      (j) Level of consumer activation; and
      (k) Preferred modality and time for communication (e.g., phone, e-mail, text, Web portal, etc.)

    Question: In the commentary, contractual arrangements are mentioned, but then later it is stated that all elements of the standard must be addressed. So is compliance with this standard dependent upon contract stipulations or the standard itself?

    Response: The standard is required as written unless the organization has specific contract language with one or more clients that prohibit an element from being addressed or prohibit the assessment process. If that is the case, when you submit your desk top review please upload into AccreditNet evidence of the limitations in contract language specifically related to the assessment process or categories required by DM 21.

  • DM 23: Consumer Activation

    + Details

    The organization incorporates consumer activation concepts into its disease management program by implementing written policies and/or documented procedures that specify:

      (a) What information the disease management program will make available to support consumer activation;
      (b) What relevant information, guidance and consumer activation support tools it will make available to disease management staff that interface directly with consumers;
      (c) The process for engaging consumers in the consumer activation process;
      (d) The process for documenting results of the initial patient activation measurement;
      (e) The procedure for tailoring coaching support based on the consumer’s level of activation; and
      (f) Periodic consumer activation re-assessment, which must be at least annual for those still participating in the disease management program.

    Question: I would like to have a brief conversation (or email if preferred) if possible regarding what URAC will be looking for to assess consumer activation. We currently have a process in place that evaluates / measures behavioral change, importance willingness and confidence to making changes / readiness to change and wanted to see if that is in line with URAC's vision as it relates to consumer activation or if there needs to be a tool specifically labeled / identified as consumer activation.

    Response: In the Glossary for Health Accreditation Standards, URAC defines consumer activation as: "An individual's motivation to engage in adaptive health behavior that may, in turn, lead to improved health outcomes". There is an additional interpretive note in the Glossary, which states: "The motivation to take actions representing adaptive health behaviors emerges from the influence of psychological factors and personal competencies, which include an individual’s understanding of his/her role in managing his/her own health care, as well as the knowledge, skill, preferences and confidence for managing his/her own health/health care. [Source: Based on a definition from Hibbard JH, Stockard J, Mahoney ER, et al. Development of the patient activation measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res 2004; 39:1005-26.] Interpretive Information in the current version of the Accreditation Guide for Disease Management, Version 4.0 DM 23 it states: "URAC does not require a DM program to use any particular consumer activation assessment tool. DM programs may develop their own or choose from existing tools (e.g., 2-item scale “Conviction Confidence Ruler” or the 13-item scale “Patient Activation Measure” (PAM), etc.)" Thus, the process and measure(s) used is determined by the applicant organization. On desk top review, policies and procedures must be submitted documenting the selected process and measurements and the steps followed in assessment and documentation. URAC will review the P&PS to ensure that all elements of the standard are addressed. During the onsite visit, URAC will audit case file records for evidence of the process, measurement, and documentation as set forth in your policies and procedures in compliance with DM 23.

  • DM 24: Consumer Engagement

    + Details

    The disease management program provides for timely contact with eligible consumers according to criteria that address:

      (a) The time frame under which the disease management program will initiate contact with eligible consumers, which must be no greater than three months after identification of the eligible consumer;
      (b) The method(s) and frequency for contacting consumers;
      (c) The method of tracking contacts with eligible consumers;
      (d) How the effectiveness of the consumer engagement process is measured and reported to purchasers; and
      (e) The process for communicating the disease management program’s policies for consumers to give or revoke consent for disease management program services.

    Question: Please clarify whether DM 24d requires the DM Program to report the program participants’ engagement rate to purchasers, even if the purchasers do not request or require this type of reporting. I am finding that small group employers do not seek this type of reporting and therefore the DM Programs are not providing it. This may be due to the confidentiality issues that arise with < 100 participants within the small groups. The consumer engagement rate is reported internally to the quality committee within the DM companies, however. Is that enough to meet the requirements of DM 24d? If not, could the report be provided in a combined aggregate to small group purchasers upon request?

    Response: This inquiry has been previously interpreted as follows and it has been determined that reporting to purchasers is required by element (d) but that for small groups of <100 aggregate reporting is acceptable. Also note that the suggestion for an alternate ROI exception remains an option. An FAQ will be developed.

    "As you know the Interpretive Information for DM 24(d) in the current version of the Accreditation Guide states the client reporting requirements as follows: "Compliance with DM 24(d) may be documented with reports to the disease management program’s client, indicating the number or rate of consumers contacted within the program’s specified time frame, and the results. Results include the number of participants as a percentage of the number of eligible consumers, the number of consumers who have opted out or declined services (or opted in, if that is the program model), and the number of consumers who could not be contacted." In the case of employer purchasers, they become the client. The data required by DM 24(d) is to suggest an ROI assessment on the DM program investment made by the purchaser. For smaller employer groups (e.g. less than 100 employees), it would be reasonable for the entire attributed population of employees covered by the benefit contract to be used as the denominator. So, unless the employee group covered is less than 30, there should not be a potential breach of confidentiality in the aggregate numbers. In the smallest groups, an alternate ROI accounting could be proposed as an exception."

    Question: For desktop, first bullet point under evidence "supporting exhibits describing consumer engagement methods and measures", is this on an individual consumer records or is this to be a report of the entire DM population engagement?

    Response: On desk top review for DM 24 in Disease Management v 4.0, the document(s) submitted should describe your methodology for contacting individual consumers - specifically as stated in the Accreditation Guide Interpretive Information "a timeline for contacting consumers that specifies milestones in the engagement process and when they will occur," and "the process of contacting consumers, and how it will take place" including "specifying how the outbound contact will be made with consumers (e.g. phone calls or mail or both). Records on contacts with consumers will be audited on a case-by-case basis during the onsite to verify compliance with the standards and your policies and procedures. Note that your tacking system also is required to show evidence of contact with consumers who decline to participate. The Guide also states that "Compliance with DM 24(d) may be documented with reports to the disease management program’s client, indicating the number or rate of consumers contacted within the program’s specified time frame, and the results". Such reports would be aggregate in nature for the entire DM population. For element (e) re: consent, is audited in case files. So, the answer to your inquiry is that some exhibits for desk top will describe how consumers are engaged on an individual basis and how you measure your results for the entire DM population.

    Question: For this standard and others that require input from providers, must the provider actually be involved in hands-on clinical care? Or is it sufficient if the provider does not see any patients but is active in the filed: was on the editorial board that recently produced ACOG's "Your Pregnancy and Childbirth" - one of the most widely published and used guidebooks for patients in pregnancy; and continues to participate in ABOG's Maintenance of Certification program, and includes the OB elements in that process. The provider also oversees the clinical quality of an entire group which performs more than 10,000 deliveries per year, and gets involved with reviewing any cases with questionable outcomes.

    Response: To comply with DM 24 and DM 3 the individual must be either a practicing provider or a content expert. Thre qualifications described in your inquiry would meet the interpretation of "content expert". However, your organization should be sure that some review is done by actively practicing providers. Note that the URAC definition of "provider" is not exclusive to physicians. The definition can be found in the Glossary included in the Accreditation Guides for Disease Management 3.0 and the current version, 4.0.

  • DM 25: Program Interventions

    + Details

    The disease management program selects and implements program interventions for participating consumers' clinical conditions and risk factors that:

      (a) Are based on medical or scientific evidence or clinical practice guidelines;
      (b) Are based on available data, including assessment information and stratification assignment, as applicable for that individual consumer;
      (c) Include an individualized plan of care for those consumers that have had an individual assessment and per the organization's policies;
      (d) Include providing self-management tools and information for consumers to use, as applicable:
        (i) During transitions of care; and
        (ii) During interactions with health care providers;
      (e) Include referral to other resources, as applicable; and
      (f) Are tracked for each participating consumer.

    Question: For a plan of care, is it necessary to have a problem statement identified, or is it sufficient to have the goals, interventions and barriers available.

    Response: For Case Management, URAC defines a Case Management Plan as "A comprehensive plan that includes a statement of problems/needs determined upon assessment; strategies to address the problems/needs; and measurable goals to demonstrate resolution based upon the problem/need, the time frame, the resources available, and the desires/motivation of the client". Note the specific reference to statement of problems/needs. Thus, while the standards wording focuses on goals, a problem statement is required for Case Management plans per the definition. For Disease Management, DM 21 requires an assessment; this is defined by URAC as: "a process for evaluating individual consumers that have been identified as eligible for a medical management program, such as disease management or case management, to identify specific needs relating to their clinical condition and associated co-morbidities". DM 25(c) requires "an individualized plan of care". The identification of specific needs commonly results in statement of a problem (or risk) to be addressed. However, the URAC DM standards do not specifically require a problem statement in order to document needs. If a documentation system is devised that leads to the identification of specific needs expressed in selected interventions and goals, then DM 25 would be met. Interpretive information in the current version of the DM 4.0 Accreditation Guide use the term "disease management plan of care"; however, the term is not defined. Your inquiry will be referred to the appropriate URAC staff to consider whether a definition should be developed.

  • DM 29: Plan Addressing Delivery of Health Information to Consumers

    + Details

    The disease management program has a documented plan addressing the delivery of health information to consumers, including family and/or caregiver:

      (a) Targeting one or more of a consumer’s information needs for the consumer's chronic condition(s);
      (b) Proactively providing health information to the individual consumer;
      (c) Supporting one or more of the following:
        (i) Informed decision making;
        (ii) Skill building and motivation for effective self-care and healthy behaviors related to the consumer’s information needs for the chronic condition; and
        (iii) Consumer comfort and acceptance.
      (d) Promoting the use of information tailored to the individual consumer’s specific needs and characteristics, including health literacy levels;
      (e) Providing health information that is accurate, comprehensive, and easy to use; and
      (f) Using community resources and other health care partners to provide health information to consumers.

    Question: For health tools for informed decision making, skill building and motivation, etc we'd like to use some of those URAC provides available to consumers on www.urac.org/consumers, however, our internal policy states we will not use resources greater than 5 years old. The date on theses URAC documents is Oct. 2009. Will you be updating these resources?

    Response: There is not a current objective for URAC to update the existing tools in 2014. We suggest you take a look at the tools available from other sources if you want to continue to use the 5 year rule for currency of your consumer information provided to consumers per DM 29.

  • DM 30: Evaluation of Consumer Health Information

    + Details

    As part of its documented plan addressing the delivery of health information to consumers, the disease management program provides health information that is accurate and appropriate for the population served by:

      (a) Having providers with current knowledge relevant to the information review it prior to its release and thereafter at least annually to ensure that it is based on current medical or scientific evidence or clinical practice guidelines; and
      (b) Having the medical director (or equivalent designate) or clinical director (or equivalent designate) approve the information to be released to consumers.

    Question: Please provide guidance on how to approach DM 30a when using commercial written health education materials. Can the requirements of element a be met through documentation from the commercial organization, similar to the process for commercial UM guidelines such as MCG?

    Response: Yes, compliance with DM 30(a) could be demonstrated via documentation from a commercial source. Alternatively, the DM organization could use a provider advisory committee to do the annual review to assure that the selected commercial product remains appropriate for the program design of the organization. Suggest looking at the HUM criteria review process as a model.

Disease Management Version 3.0

  • Standard 23: Plan Addressing Delivery of Health Information to Consumers

    + Details

    The organization has a documented plan addressing the delivery of health information to consumers:

    1. Targeting one or more of a consumer's information needs for the current episode of care;
    2. Proactively providing health information to the individual consumer;
    3. Supporting one or more of the following: 
      1. Informed decision making;
      2. Skill building and motivation for effective self-care and healthy behaviors related to the consumer's information needs for the current episode of care; and
      3. Consumer comfort and acceptance.
    4. Promoting the use of information tailored to the individual consumer's specific needs and characteristics, including health literacy levels; and
    5. Providing health information that is accurate, comprehensive, and easy to use;and
    6. Using community resources and other health care partners to provide health information to consumers.

    Question: Do we have to have implemented a plan for the delivery of health information to consumers?

    Response: No, applicant organizations need to have a documented plan, reviewed by the requisite leadership for disease management that indicates what structures and processes the organization needs to put into place in order to proactively provide health care information to consumers.

  • Standard 24: Evaluation of Consumer Health Information

    + Details

    As part of its documented plan addressing the delivery of health information to consumers, the organization provides health information that is accurate and appropriate for the population served by:

    1. Having providers with current knowledge relevant to the information review it prior to its release and thereafter at least annually to ensure that it is based upon current clinical principles, processes and when available, evidence based information;
    2. Having the medical director (or equivalent designate) or clinical director (or equivalent designate) approve the information to be released to consumers.

    Question: Why does health information need to be reviewed prior to giving it to the consumer?

    Response: Information provided to the health care consumer should be reviewed by providers with current knowledge of the subject matter to ensure that it is current and accurate.

Drug Therapy Management Version 2.0

  • Standard 7: Periodic Consumer Reassessment Process

    + Details

    Question: Under this new standard, how often does the organization have to reassess the participating consumers?

    Response: The URAC standard is not prescriptive regarding the frequency with which consumer reassessments are conducted. The organization should specify appropriate, specific timeframes for reassessments in its policies and procedures for this process.

  • Standards 21, 22 and 23: Program Evaluation: Process, Outcome, and Methodology Disclosure

    + Details

    Question: Since the evaluation of the program is a key focus of these new standards, what is expected by an organization?

    Response: An organization should have a mechanism for evaluating the success of its program offered. This evaluation includes the assessment of clinical/health related benefits financial benefits, and the impact of a specified program. The program evaluation benefits (outcomes) must be reported to current and prospective purchasers/clients, and the evaluation methodology used to determine the program evaluation must also be disclosed.

Health Network Version 6.0

  • Standard N-CR 18: Credentialing Phase-In

    + Details

    The organization implements the credentialing program required by N-CR 1 according to time frames that are no longer than the following:

    1. At the time of the on-site review, the organization has completed the credentialing process for at least 100 practitioners;
    2. Credentialing of at least 50% of participating providers within the scope of the credentialing program will be completed within two years from the date the organization initially receives URAC accreditation; and
    3. Credentialing of all participating providers within the scope of the credentialing program will be completed within three years from the date the organization initially receives URAC accreditation.

    Question: What happens if a network accreditation applicant comes up for re-accreditation in three years and has not completed credentialing of all providers within the scope of the credentialing program?

    Response: Standard N-CR 18 is Mandatory; therefore, the applicant organization would not be meeting element (c) and as a result would not be eligible for a full accreditation.  Please note that this standard does not apply to Health Plan accreditation.

Health Plan Version 6.0

  • Standard P-MR 2: Consumer Information Disclosure

    + Details

    Information available to consumers includes:

    1. Descriptions of the processes the organization uses to provide information and support to consumers: [--]
      1. For whom English is not their primary language; an
      2. With special needs, such as cognitive or physical impairments.
    2. List of providers that are in the provider network;
    3. Descriptions of participating provider compensation arrangements;
    4. The tools the organization makes available to assist in self-managing care;
    5. Consumer satisfaction statistics;
    6. Administrative requirements;
    7. Medical management requirements;
    8. How the health benefits program works;
    9. Financial responsibilities for consumers, including potential out-of-pocket costs, such as deductibles, co-pays, co-insurance, annual and lifetime co-insurance limits, and changes that could occur during the enrollment period;
    10. Health benefits decision-making responsibilities for consumers;
    11. Condition-specific criteria for benefits; and
    12. Coordination of benefits.

    Question: Are there any requirements in the Health Plan standards related to consumers for whom English is not their primary language or who have special needs?

    Response: Yes, the most recent version of the Health Plan standards requires applicant organizations to submit a description of how they accommodate consumers with those particular types of needs.  This would be confirmed during the on-site review through management and staff interviews for the customer support areas.
  • Standard P-MR 3: Consumer Communications Plan

    + Details

    The communications plan (required under Core 22) provides that at the time of enrollment, consumers are provided with materials that clearly explain:

    1. Instructions on how to receive assistance via e-mail, telephone, or in person;
    2. The scope of covered benefits;
    3. How to access covered benefits, including:
      1. (i) Requirements for prior authorization;
      2. Accessing emergency services and out-of-service-area services; and
      3. On-going access to current drug formulary;
    4. Cost-sharing features under the benefits plan;
    5. How to obtain the cost of covered benefits;
    6. Any obligations for consumers to cooperate with the organization’s medical
    7. Coverage exclusions;
    8. How to obtain evidence-based health information and content for common conditions, diagnoses, and the treatment, diagnostics and interventions;
    9. Complaint and appeals processes available to consumers.

    Question: Do Health Plans have to do anything additional as far as their consumer communications plan?

    Response: Yes, for P-MR 3 they need to provide consumers with materials that clearly explain how to obtain evidence-based health information and content for common conditions and diagnoses, along with the treatment, diagnostics and interventions.

  • Standard P-UM 1: Independent Review Process

    + Details

    The organization has a mechanism for consumers to access an independent review process, after all internal appeal mechanisms have been exhausted, for clinical determinations relating to the necessity or appropriateness of medical services (including determinations that proposed medical services are experimental in nature).
    The independent review entities conducting the independent review process:

    1. Must access and rely on appropriate clinical expertise in rendering independent review determinations;
    2. Must not have any direct financial interest in the organization or in the outcome of the independent review;
    3. Render determinations for non-urgent cases, within thirty calendar days from the date the consumer initiated the independent review;
    4. Render determinations for cases involving urgent care, within 72 hours from the date the consumer initiated the independent review;
    5. May not have been involved in the original determination under appeal.

    Question: The UM standard specific to Health Plans looks different, but reads the same.  Was there any change to the intent or language?

    Response: No, P-UM 1 was simply reorganized to clearly show that the elements within the standard describe requirements for an independent review entity that the health plan would use for the independent review process.

Health Plan/Health Network Version 6.0

  • Standard P/N-NM 15 & 16: Provider Dispute Resolution Mechanisms

    + Details

    P/N-NM 15 – Disputes Involving Professional Competence or Conduct
    The organization implements a mechanism to resolve disputes with participating providers regarding actions by the organization that relate to a participating provider's status within the provider network and any action by the organization related to a provider's professional competency or conduct.  That mechanism:

    1. Specifies that all disputes are referred to a first-level panel consisting of at least three qualified individuals, of which at least one must be a participating provider who is not otherwise involved in network management and who is a clinical peer of the participating provider that filed the dispute;
    2. Includes the right to consideration by a second-level panel and the methods to request such consideration; and
    3. Provides for consideration to a second-level panel consisting of at least three individuals that comply with element (a) of this standard and that were not involved with the first-level panel.

    P/N-NM 16 – Disputes Involving Administrative Matters
    The organization implements a mechanism to resolve disputes with participating providers not covered by N-NM 14 that offers the disputing provider the right to consideration by an authorized representative of the organization not involved in the initial decision that is the subject of the dispute. [M]

    Question: Do the provider dispute resolution mechanisms found in P/N-NM 15 and 16 preclude having the same individuals involved in the original dispute reconsider the matter given additional input from the provider?

    Response: No, these standards do not prohibit a re-review of the matter by those involved in the original dispute; however, if such a re-examination does not result in a satisfactory resolution from the provider's perspective, then the dispute resolution mechanism remains available to the provider.

  • Standard P/N-CR 12: Credentialing Time Frame

    + Details

    The organization does not submit for initial review any credentialing application that:

    1. Is signed and dated more than 180 days prior to credentialing committee review; or
    2. Contains primary or secondary source verification information collected more than six months prior to review.

    Question: We've heard that some accrediting bodies are allowing credentialing applications to be signed and dated up to 360 days prior to credentialing committee review.  Do URAC credentialing standards allow for credentialing applications to be signed/dated that far in advance of initial committee review?

    Response: No, with the latest revision of the Health Plan and Health network standards, this timeline did not change, such that a credentialing application cannot be signed and dated more than 180 days prior to initial credentialing committee review.

  • Standard P/N-CR 13: Credentialing Determination Notification

    + Details

    The organization provides written notification to providers of the determination of the providers' credentialing application within ten (10) business days of the determination.

    Question: Did URAC tighten up the time frames for notification of a credentialing determination?

    Response: Yes, with the most recent version of the Health Plan and Health Network standards (version 6.0), standard P-CR 13/N-CR 13 changed from "60 calendar days" to "10 business days."

  • Standard P/N-CR 17: Credentialing Delegation

    + Details

    The organization complies with the Core Standards for any credentialing functions it delegates to another entity.  In addition, the organization:

    1. Retains authority to make the final credentialing determination regarding any provider; and
    2. At least every three years, conducts on-site surveys of each entity that performs credentialing functions on behalf of the organization.

    Question: Is it a requirement to conduct on-site surveys of entities delegated credentialing?

    Response: Yes, the requirement is for an organization to conduct on-site surveys of delegated entities every three (3) years.

Health Utilization Management 7.2

  • HUM 1: Review Criteria Requirements

    + Details

    The organization utilizes explicit clinical review criteria or scripts that are: (No Weight)

      (a) Developed with involvement from appropriate providers or prescribers with current knowledge relevant to the criteria or scripts under review; (3)
      (b) Based on current clinical principles and processes; (3)
      (c) Evaluated at least annually and updated if necessary by: (3)
        (i) The organization itself; and (3)
        (ii) Appropriate, actively practicing physicians, pharmacists, and other providers with current knowledge relevant to the criteria or scripts under review; and (Mandatory)
      (d) Approved by the medical director (or equivalent designate), clinical director (or equivalent designate), P&T Committee or other equivalent clinical oversight body. (Mandatory)

     

    Question: Are medical policies considered review criteria?

    Response: Yes, medical policies used to make medical necessity determinations are within the scope of HUM 1. Policies related to eligibility or coverage are considered administrative and are not in scope.

    Question: I have a question regarding vendor oversight versus delegation oversight. Are there specific criteria surrounding how URAC requires the Health Plan to oversee their particular entity? 

    Response: URAC requirements for oversight of delegated entities or contracted vendor as depends on the scope of the relationship. If the contractor is performing functions that are part of the service(s) for which you are accredited (e.g. Appeals), then Core 9 applies as well as Core 8(b) and (e) apply. If the contracted vendor supplies support services only and handles PHI, then oversight focuses on proper handling of PHI, including staff training, policies and procedures, and proper handling systems and techniques. This is monitored by URAC under Core 4.

  • HUM 2: Access to Review Staff

    + Details

    The organization provides access to its review staff by a toll free or collect telephone line at a minimum from 9:00 a.m. to 4:00 p.m. of each normal business day in each time zone where the organization conducts at least two percent of its review activities. (4)

     

    Question: CORE 2: Would company intranet publication meet this standard?

    Response: Yes, a company intranet publication could be submitted as evidence of compliance for any or all of the elements in Core 2.

  • HUM 4: Review Service Disclosures

    + Details

    The organization: (No Weight)

      (a) Requires utilization management staff to identify themselves by name, title, and organization name; and (2)
      (b) Upon request, verbally informs patients, facility personnel, the attending physician and other ordering providers, and health professionals of specific utilization management requirements and procedures. (4)

     

    Question: In the processes we write and adapt to meet URAC standards, can the term "Protected Health Information" (or "PHI") be considered synonymous with "Individually Identifiable Health Information" or must our documentation include both terms? e.g. "Protected Health Information or Individually Identifiable Health Information" 

    This general question covers multiple standards.

    Response: Yes, you may use PHI as a comprehensive term. We suggest you include definitions in your policies and procedures that make clear that you mean "PHI" to be inclusive. Then you will have evidence of compliance with Core 4, Core 16 and other standards requiring confidentiality of consumer information.

  • HUM 10: Initial Clinical Reviewer Qualifications

    + Details

    Individuals who conduct initial clinical review possess an active, professional license or certification: (No Weight)

      (a) To practice as a health professional in a state or territory of the United States; and (Mandatory)
      (b) With a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review. (Mandatory)

     

    Question: If a nurse is performing remote clinical review and covering multiple states in review, must the nurse hold licensure in each state, assuming that these state are not compact?

    Response: URAC standards do not address the issues related to multi-state licensure for nurses. URAC will expect the accredited organization to follow its own policies for compliance with HUM 10. However, that said, conducting clinical review for medical necessity determinations is not usually considered the practice of nursing as it falls outside the common scope of practice defined by most states regulations. 

    Question: Can you please tell me if there is anywhere in the standards that require us to identify the name of the nurse doing the initial clinical review to the provider requesting the service? I am specifically interested in the requirement to give the name of the clinical nurse reviewer when the service is certified. All non-certifications contain the name of the peer clinical reviewer. I do not see a requirement in HUM 10, 11 or 12, and HUM 4 refers to access to review staff is only discussing review requirements and procedures, not certifications.

    Response: HUM 22 & 23 address content required in both verbal and written certification notices. Nothing in these two standards or in the Interpretive Information in the current version of the Accreditation Guide for HUM v 7.2 requires disclosure of the name of the nurse conducting the initial clinical review when an inbound phone call is not the means by which the review is conducted. Disclosure of the name of the nurse is required under HUM 4 if the determination is made during an inbound phone call. Common courtesy would dictate that if an outbound call is made for notification of the certification, the nurse disclose her/his name and title. But it is correct to say that URAC standards are silent regarding disclosure of the initial clinical reviewer's identity on certification notices - whether verbal or written.

  • HUM 14: Peer Clinical Reviewer Qualifications

    + Details

    Individuals who conduct peer clinical review are clinical peers who: (No Weight)

      (a) Hold an active, unrestricted license or certification to practice medicine or a health profession in a state or territory of the United States; (Mandatory)
      (b) Unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting a peer clinical review; (Mandatory)
      (c) Are qualified, as determined by the medical director or clinical director, to render a clinical opinion about the medical condition, procedures, and treatment under review; and (Mandatory)
      (d) Hold a current and valid license: (Mandatory)
        (i) In the same licensure category as the ordering provider; or (No Weight)
        (ii) As a doctor of medicine or doctor of osteopathic medicine. (No Weight)

     

    Question: HUM 14 Peer Clinical Reviewer Qualifications. We use an IRO for some of our peer clinical reviews. Our contracted IRO is URAC-accredited. Must we have their reviewers' personnel files available for the onsite review or are we exempt from this due to their accreditation?

    Response: Since you delegate to a URAC-accredited IRO, you may depend on that organization's accreditation to comply with the pertinent standards. You will need a current signed contract with them and proof of their current URAC accreditation. Proof of accreditation is obtained by downloading and printing their URAC Accreditation Summary Report available on the URAC website.

  • HUM 15: Drug Utilization Management Reviewer Qualifications

    + Details

    When conducting drug utilization review: (No Weight)

      (a) In addition to the initial clinical reviewers described in HUM 10, certifications (only) can be rendered by pharmacy technicians who: (No Weight)
        (i) Follow HUM 1 established criteria; and (Mandatory)
        (ii) If required by state law, possess an active professional relevant license in good standing; and (Mandatory)
        (b) In addition to the clinical peers described in HUM 14, non-certifications (as well as certifications) can be rendered by pharmacists who: (No Weight)
      (i) Hold an active, unrestricted license or certification to practice pharmacy in a state or territory of the United States; (Mandatory)
      (ii) Unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting drug utilization review; (Mandatory)
      (iii) May not conduct peer clinical review non-certifications for drug utilization management if prohibited by state utilization management laws; and (Mandatory)
      (iv) May not conduct peer clinical review non-certifications for drug utilization management if the requesting party specifically requests a clinical peer. (Mandatory)

     

    Question: HUM 15 Drug UM Reviewer Qualifications- In reviewing the onsite requirements, we see that the scope of the review is "all drug utilization review conducted by the applicant organization". For the onsite, the auditor will review authorization requests as they appear on staff's information management system to verify the use of algorithms and non-automated requests. Our question is: Will URAC request additional files to ensure that there are drug utilization management files for them to review? 

    Response: URAC reviews HUM 15 as part of the interview of the Senior Clinical Staff Person, as a part of staff qualifications in personnel file review and as part of the case file audit. If an organization is implementing HUM 15, then the URAC Reviewer will stratify the case file selection in order to capture some Drug UM reviews. No additional files are requested for this purpose.

    Question: We are currently accredited under HUM V.7.0 and seek reaccreditation under HUM V. 7.2. are we retrospectively held accountable for modification/additions included in V.7.2 but were NOT part of our accreditation; V.7.0?

    We understand that we must meet the standards in V.7.2 going forward. But because this is the first time the standards have changed since our initial accreditation in 2006, we don't have a clear understanding of how the new version impacts the look-back findings.

    Response: For HUM 15 and any new requirement in v 7.2 that was not in v 7.0, the look back period begins on the date you submit your desk top review for the new version. URAC interprets your desk top submission as the date you believe that you are able to comply with the standards requirements. 

    Question: Regarding HUM 15a and the use of pharmacy technicians...is it sufficient for the pharmacy tech to have access to a physician when assistance is required with application of an algorithm OR must the organization provide the pharmacy tech with access to a pharmacist in these situations?

    Response: Interpretive Information for HUM 15 in the current version of the HUM v 7.2 Accreditation Guide is very specific in stating that the Pharmacy Technician works under the supervision of a Pharmacist and per the Points to Remember "The pharmacy technician has access to a pharmacist when assistance is required with the application of the algorithm". A physician should not be substituted for this pharmacy function; the knowledge base and skill sets are different. URAC assumes that the algorithms have been developed by pharmacists for DRUM activities performed by Pharmacy Technicians. 

  • HUM 16: Prospective, Concurrent and Retrospective Drug Utilization Management

    + Details

    The organization ensures drug utilization management mechanisms using the available information and data addressing the following, where appropriate: (Mandatory)

      (a) Therapeutic appropriateness; (No Weight)
      (b) Over and underutilization; (No Weight)
      (c) Generic use; (No Weight)
      (d) Therapeutic interchange; (No Weight)
      (e) Duplication; (No Weight)
      (f) Drug-disease contraindications; (No Weight)
      (g) Drug-drug or drug-allergy interactions; (No Weight)
      (h) Drug dosage; (No Weight)
      (i) Duration of treatment; (No Weight)
      (j) Clinical abuse or misuse; (No Weight)
      (k) Drug-age precautions; (No Weight)
      (l) Drug-gender precautions; (No Weight)
      (m) Drug-pregnancy precautions; (No Weight)
      (n) Regulatory limitations; and (No Weight)
      (o) Benefit design. (No Weight)

     

    Question: As pharmacy UM has been added to the new HUM standards, do medically benefitted drugs fall under the scope of these standards?

    Response: Yes, while PBM accreditation is considered the gold standard for organizations solely performing Drug Utilization Management, an organization accredited under HUM may perform Drug Utilization Management per HUM 16. The PBM engages in Drug Utilization Management in accordance with PBM standards DrUm 1 through 27.

    Question: We previously asked the question below. Does this also hold true for existence of policies and procedures? For example, it is acceptable to only have a P&P for concurrent review and not prospective and retrospective review for element g drug-drug or drug-allergy interactions.

    Previous Inquiry: For HUM 16, can you help us understand what “where appropriate” means in stem of the standard? We reviewed the first bullet under the interpretive guide, but does “where appropriate” also mean that for prospective, concurrent and retrospective DUR, each element (a - o) may not always be applicable? 

    For example, for DUR we define prospective review as a time prior to the point of sale when the physician prescribes a medication. Concurrent review is at the point of sale and retrospective review is after the point of sale where we analyze historical drug utilization and identify opportunities to encourage clinically appropriate utilization. Using those definitions, is it appropriate, for example, to address element g (drug-drug or drug-allergy interactions) for concurrent review (which is at the point of sale), but not for prospective or retrospective review?

    Response: Yes, you are interpreting HUM 16 correctly. The Interpretive Information in the current version of the HUM v 7.2 Accreditation Guide states: "The elements of standard HUM 16 are reviewed as appropriate for any given utilization review; it is not the intent of this standard for organizations to address all elements of this standard for every review. The organization determines the key elements of the review based on its clinical criteria and review policies, taking into account the information available to conduct the review." Thus, some of the listed elements may be applicable based on such things as the point in time of the review, the qualifications of the reviewer, applicability of various precautions to a particular drug or to the individual consumer, and even something like access to plan benefits information.

  • HUM 17: Peer-to-Peer Conversation Availability

    + Details

    Health professionals that conduct peer clinical review are available to discuss review determinations with attending physicians or other ordering providers. (4)

    Question: We have a question about the above UM standards. UM 17 discusses the peer to peer conversation availability and the goal of the peer to peer conversation is to allow the treating provider a chance to discuss a UM determination before the initiation of the appeal process. In the points to remember it discusses that the discussion shall be timely and the UM organization must have a back up procedure for situations where the original peer reviewer is not available, then another clinical peer is available within one business day.

    UM 18 discusses the opportunity to discuss the non-certification decision with the clinical peer reviewer making the initial determination or with a different clinical peer, if the original clinical peer reviewer cannot be available within one business day.

    My question is this:
    If the original clinical peer reviewer is never available and an alternate is always provided, is this meeting the intent of these two standards?

    Response: Yes, UM 17 & 18 assume that the alternate peer is an acceptable way to fulfill the need for a physician to physician conversation regarding a determination. This might happen, for example, when an IRO is consulted to obtain specific specialty peer reviewers. Note the "or" between 18 (a) & (b). This would not be true in states which have more specific requirements; as the Accreditation Guide suggests, you should "refer to the state regulatory requirements for requirements for peer-to-peer reviewers" to be certain of applicable requirements. URAC expects accredited organizations to comply with the most rigorous requirement.

  • HUM 18: Peer-to-Peer Conversation Alternate

    + Details

    When a determination is made to issue a non-certification and no peer-to-peer conversation has occurred: (No Weight)

      (a) The organization provides, within one business day of a request by the attending physician or ordering provider, the opportunity to discuss the non-certification decision: (No Weight)
        (i) With the clinical peer reviewer making the initial determination; or (4)
        (ii) With a different clinical peer, if the original clinical peer reviewer cannot be available within one business day; and (4)
      (b) If a peer-to-peer conversation or review of additional information does not result in a certification, the organization informs the provider and consumer of the right to initiate an appeal and the procedure to do so. (4)

     

    Question: Per the URAC Health Utilization Management Accreditation Guide v.7.2, HUM 18, Points to Remember section, bullet 8, “ documentation of the peer to peer process with notification of appeal rights should the discussion not result in a certification must be found in the written policy and/or documented procedures.”

    Is it compliant to provide the required notification of appeal rights related to a peer to peer conversation within the body of the initial denial letter [to both member and provider] along with the instructions for requesting a peer-to-peer conversation? An example of this language follows:

    If your provider would like to discuss this case with a physician reviewer, please contact the [Insert Organization Name] at [insert phone number]. If the conversation contributes information that allows authorization, you will receive additional written notification. If the conversation results in a determination to uphold the original denial, then the determination and appeal rights and instructions included in this letter, will apply.

    With the above notification of appeal rights provided prior to the peer to peer conversation, the case documentation would indicate that a peer to peer conversation took place, and include the result, i.e., upheld vs overturned. However, there would not be a notation that appeal rights were provided, as that communication already occurred in the initial denial letter as noted above.

    Please confirm that this is a compliant approach to the requirement.

    Response: HUM 18(b) is correctly interpreted as a requirement to provide appeal information at the point in time the non-certification is upheld during the Peer-to-Peer conversation - even if the appeal information was previously provided. Thus, your suggested process would comply if the determination notice follows the Peer-to-Peer conversation, but not if the conversation comes after a non-cert notice is sent. Your policies and procedures can indicate that the peer reviewer mentions or refers to the appeal information in the initial non-cert notification. The result being that the requesting provider receives the information verbally at a point in time that it is most relevant, and is also reminded of a hard copy of the appeal process the provider has already received in writing. URAC takes the position that is not a lot of extra work to require the peers to say something like "there may be appeal rights which the provider or patient may exercise - information on how to access the procedure is in the determination notice" and to document that (a simple check box and script would do it). We suspect that many providers don't actually read the determination letter - and if they do, many may stop at the outcome of the determination. A simple verbal disclosure ensures that the rights of consumers and providers is protected.

  • HUM 19: Prospective Review Time Frames

    + Details

    For prospective review, the organization issues a determination: (No Weight)

      (a) As soon as possible based on the clinical situation, but in no case later than 72 hours of the receipt of request for a utilization management determination, if it is a case involving urgent care; or (4)
      (b) Within 15 calendar days of the receipt of request for a utilization management determination, if it is a non-urgent case; and (4)
      (c) For non-urgent cases, this period may be extended one time by the organization for up to 15 calendar days: (No Weight)
        (i) Provided that the organization determines that an extension is necessary because of matters beyond the control of the organization; and (4)
        (ii) Notifies the patient, prior to the expiration of the initial 15 calendar day period, of the circumstances requiring the extension and the date when the plan expects to make a decision; and (4)
        (iii) If a patient fails to submit necessary information to decide the case, the notice of extension must specifically describe the required information and the patient must be given at least 45 calendar days from receipt of notice to respond to the plan request for more information. (4)

     

    Question: We would like some clarification on when URAC considers a UM request or appeal to be “received”. 

    • The ERISA Claims procedure indicates in paragraph (f)(4)that “the period of time within which a benefit determination is required to be made shall begin at the time a claim is filed in accordance with the reasonable procedures of a plan.” 
    • Medicare defines the receipt of request as “received by the appropriate office or department designated by the Medicare health plan”

    The URAC HUM standards 7.2 do not appear to define “the receipt of a prior authorization request”. It has been our experience that URAC looks for the date of the receipt on the fax. We have been experiencing issues where providers or member misdirect their “urgent” request to a Department or fax number that is not associated with our UM programs, or mails in an “urgent” request. 

    Is it permissible within the URAC HUM Standards for us to define “the receipt of a prior authorization request” in our policy, to be certain about when the turnaround time clock begins? 

    Response: Yes, an organization's policies can specify when a request is considered to be received. However, for HUM 19, 20 21 and for appeals (HUM 38 & 39) URAC defines the start time as when the request is received by the organization - wherever it is received. So, if the FAX goes to the wrong department, the clock still starts ticking when it is received there. URAC also expects that when URAC standards or interpretations conflict with state or federal laws or regulations such as the Medicare definition cited in your inquiry, the accredited organization will comply with the most rigorous. So, the Medicare definition is less rigorous than URAC's and we will expect your definition to reflect that the time for completion of any type of review begins when the request is received at any location within your organization.

  • HUM 20: Retrospective Review Time Frames

    + Details

    For retrospective review, the organization issues a determination: (No Weight)

      (a) Within 30 calendar days of the receipt of request for a utilization management determination; and (3)
      (b) This period may be extended one time by the organization for up to 15 calendar days: (No Weight)
      (i) Provided that the organization determines that an extension is necessary because of matters beyond the control of the organization; and (4)
      (ii) Notifies the patient, prior to the expiration of the initial 30 calendar day period, of the circumstances requiring the extension and the date when the plan expects to make a decision; and (4)
      (iii) If a patient fails to submit necessary information to decide the case, the notice of extension must specifically describe the required information and the patient must be given at least 45 calendar days from receipt of notice to respond to the plan request for more information. (4)

     

    Question: This is a generic question which pertains to all of the retrospective review standards (i.e., the time frames, notice of decision, non-certification requirements and scope of review information).

    At our organization, our UM review process includes 1-an initial review by a dentist advisor; 2-a second review conducted by a different dentist advisor); and, 3-an appeal. It's important to note that the second review is not a state requirement, but rather a courtesy provided by our organization. 

    Question: Can you confirm if the retrospective review standards would apply to the second review?

    Response: The Glossary found in the Accreditation Guide for Health Utilization Management v 7.2 defines retrospective review as follows: "Review conducted after services (including outpatient procedures and services) have been provided to the patient". So, whether or not your second review is considered retrospective and within the scope of HUM 20 & 31 depends on whether the review is initiated after the service has been provided. If the first review results in a non-certification and the treatment or service has not been provided, then the second review would still be prospective. You will want to determine which category is applicable 9and thus which standards) on a case-by-case basis.

  • HUM 23: Continued Certification Decision Requirements

    + Details

    Confirmation of certification for continued hospitalization or services includes the number of extended days or units of service, the next anticipated review point, the new total number of days or services approved, and the date of admission or onset of services. (3)

    Question: With respect to HUM 23: does URAC expect a UM organization to be calling hospital patients in their rooms routinely to convey decisions regarding concurrent stay requests, whether approved or disapproved? We deal with this by notifying hospital UM staffs who then do the notifying of parties within their hospital or SNF. I've received advice that there is an expectation that we call the hospital and the physician and the patient. I might be misunderstanding something however I'd appreciate clarification. 

    Response: URAC standards do not require that you contact patients directly when hospitalized. HUM 23 does not have language related to notification of patients; HUM 22(a) does require notice of certifications to patients but does not require that this be done via phone call; common practice is mail notification. HUM 24 speaks to notification in the case of non-certifications, but again it does not require phone calls; and common practice is to notify patients via mail. As for the IRO standards under which you are accredited, IR-INT 27 addresses only notification to the referring entity. URAC accredited companies do, in fact, communicate determinations regarding inpatient care directly to the facility - usually through the UM or CM departments; such communication often is via phone or FAX. And, as outlined in your inquiry, the inpatient is also notified by facility staff.

  • HUM 24: Written Notice of Non-Certification Decisions and Rationale

    + Details

    For non-certifications, the organization issues written notification of the non-certification decision to the patient and attending physician or other ordering provider or facility rendering service that includes: (No Weight)

      (a) The principal reasons for the determination not to certify; (4)
      (b) A statement that the clinical rationale used in making the non-certification decision will be provided, in writing, upon request; and (4)
      (c) Instructions for: (No Weight)
      (i) Initiating an appeal of the non-certification; and (Mandatory)
      (ii) Requesting a clinical rationale for the non-certification. (Mandatory)

     

    Question: We delegate the initial review of all pharmacy UM requests to our PBM which has URAC PBM accreditation. The PBM is not involved in the appeal determinations. 

    Can you clarify how the file review for both denial and appeal cases will be performed during the onsite visit? Since HUM V7.2 includes a specific drug UM appeal standard, I'm interested in how URAC would review the drug files given that the URAC accredited PBM only performs that initial review and not the appeal. If a medical director performs the appeal, will the URAC surveyor review the entire case file which would include the initial clinical review request? Hope this makes sense.

    Response: Current URAC review procedures are not to review the work done by the URAC accredited PBM to whom HUM 15 & 16 functions are delegated. So, you should expect that only the appeals work done by your organization would be subject to case file review. There will not be any additional case file pulls for HUM 15 & 16. You can depend on the procedures followed by the URAC accredited PBM for compliance with HUM 15 & 16. 

  • HUM 33: Non-Certification Appeals Process

    + Details

    The organization maintains a formal process to consider appeals of non-certifications that includes: (No Weight)

      (a) The availability of standard appeal for non-urgent cases and expedited appeal for cases involving urgent care; and (Mandatory)
      (b) Written appeal policies and procedures that: (No Weight)
      (i) Clearly describe the appeal process, including the right to appeal of the patient, provider, or facility rendering service; (Mandatory)
      (ii) Provide for explicit time frames for each stage of the appeal resolution process; and (Mandatory)
      (iii) Are available, upon request, to any patient, provider, or facility rendering service. (Mandatory)

     

    Question: Does the state in which member's plan was sold out of dictate all other UR requirements (TAT for med necessity determination-notification, same state reviewer requirements) regardless of where member received treatment?

    If member resides and receives treatment in different state than plan sold out of, which state dictates UR requirements?

    If member resides in one state, receives treatment in second state, plan sold out of 3rd state, which state dictates UR requirements?

    In above scenarios, Would HUM organization have to consider ALL applicable state UR requirements and apply most stringent?

    Response: This is a question for your legal counsel because it requires interpretation of your benefits contracts. URAC standards are not explicit on this point, but generally the state of the member's residence is the reference point for applicability of state laws and regulations regarding HUM 33 and appeals requirements.

    Question: HUM 33b states "Unless expressly allowed by state or fed. law or reg. are located in a state or territory of the US when conducting an appeals consideration". Does this mean the appeal reviewer MUST be in the US while conducting an appeal's review- including if they are temp. out of the country but still working? Ex. a working vacation

    Response: Yes, you are correct. The intent of HUM 33 in the Health Utilization Management, Version 7.0 and 7.2 is that the peer reviewer must physically be in the US or its territories when conducting a review. So, offshore vacations are included. Only a working vacation to a US territory could be considered as permitted. Note also that the same prohibition exists for initial peer reviewers in HUM 14(b).

  • HUM 34: Appeals Process

    + Details

    As part of the appeals process: (No Weight)

      (a) The organization provides the patient, provider, or facility rendering service the opportunity to submit written comments, documents, records, and other information relating to the case; (Mandatory)
      (b) Takes all such information into account during the appeals process without regard to whether such information was submitted or considered in the initial consideration of the case; and (Mandatory)
      (c) In instance of a first level appeal, the organization implements the decision of the first level clinical appeal if it overturns the initial denial. (Mandatory)

     

    Question: If we receive an appeal and it is reviewed by our medical director and denied and then additional information is submitted with the appeal, can the original appeal and new information be re-reveiwed by our medical director and the original denial be overturned? Or does the additional informaiton have to be sent for an outside review?

    Response: Yes, HUM 34(b) can be interpreted to permit consideration of additional clinical information by the initial peer reviewer or appeal reviewer. If the reviewer is able to certify the request, you should then move ahead to implement the certification per HUM 34 (c). If the reviewer is unable to certify, then a different peer reviewer must be assigned to confirm or overturn the denial decision as required by HUM 35 (d).

  • HUM 35: Appeal Peer Reviewer Qualifications

    + Details

    Individuals who conduct appeal considerations are clinical peers who: (No Weight)

        (a) Hold an active, unrestricted license or certification to practice medicine or a health profession in a state or territory of the United States; (Mandatory)
        (b) Unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting appeal considerations; (Mandatory)
        (c) Are in the same profession and in a similar specialty as typically manages the medical condition, procedure, or treatment as mutually deemed appropriate; (Mandatory)
        (d) Are neither the individual who made the original non-certification, nor the subordinate of such an individual; and (Mandatory)
        (e) Are board-certified (if applicable) by: (3)
        (i) A specialty board approved by the American Board of Medical Specialties (doctors of medicine); or (No Weight)
        (ii) The Advisory Board of Osteopathic Specialists from the major areas of clinical services (doctors of osteopathic medicine); or (No Weight)
        (iii) The American Dental Association’s (ADA) specialty boards or the American Board of General Dentistry (ABGD); or (No Weight)
        (iv) The American Board of Podiatric Surgery (ABPS) or the American Board of Podiatric Medicine (ABPM). (No Weight)

     

    Question: This question concerns a statement on page 231 concerning HUM 35.e where is states that the "Appeal Case review documentation must be legible, including the identity of the appeal peer reviewer."

    Does the "Appeal case review documentation" include the appeal letter sent out to the member or provider? If so, does this mean that the actual name of the peer reviewer must be on the appeal letter or can a Peer Reviewer ID number be used on appeal letters that correlates to the internal documentation of the identity of the appeal reviewer?

    Response: HUM 41 (e) requires that the "Name and credentials of the clinical peer that meets the qualifications in standard HUM 35" be included in the appeal record documentation. Nothing in URAC standards requires that the name of the reviewer be disclosed in the notification of determination. We believe that the Points to Remember bullet re: legibility speaks to handwritten per review notes. 

    Question: Part e. of this standard indicates that the individuals who conduct appeals considerations are clinical peers who are board-certified (if applicable) by:

    i. A specialty board approved by the American Board of Medical Specialties (doctors of medicine); or ii. The Advisory Board or Osteopathic Specialists from the major areas of clinical services (doctors of osteopathic medicine); or iii. The American Dental Association's (ADA) specialty boards or the American Board of General Dentistry (ABGD); or iv. The American Board of Podiatric Surgery (ABPS) or the American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM).

    Do these clinical peers have to be board-certified? Or will it be acceptable (comply with URAC standard) if these clinical peers are board-eligible? Since this element is not mandatory, must we meet the board-certified element to comply with this standard?

    Response: URAC does not recognize the category of "Board eligible" as being in compliance with HUM 35(e). However, this is not a mandatory element. Compliance with this element is audited during the onsite visit via case file review. A minimum score of 80% of files reviewed is necessary for full compliance to be scored. Should that level of compliance not be found, points are lost from your overall score towards a Full Accreditation status. Accreditation status is determined through a formula where the HUM standards are weighted 70% of the total. A score of 94% or better is required for Full Accreditation. So, it is possible not to meet HUM 35(e) and still be accredited.

  • HUM 37: Reviewer Attestation Regarding Credentials and Knowledge

    + Details

    For each appeal case they accept, reviewers attest to: (No Weight)

      (a) Having a scope of licensure or certification that typically manages the medical condition, procedure, treatment, or issue under review; and (4)
      (b) Current, relevant experience and/or knowledge to render a determination for the case under review. (4)

     

    Question: HUM 37 Evidence for Meeting Standard-Desktop Review Materials includes policies, an attestation template and reviewer training on experience and knowledge requirements, attestation and process to recuse themselves. We have an appeals policy but since we do not perform appeals, must we also submit the other two items?

    Response: While HUM 37 does not contain mandatory elements, we recommend that you write the attestation procedure into your appeals policies and procedures. It need not be extensive but sufficient to show intent to comply with the two elements of the standard if circumstances change in the future.

  • Health Utilization Management 7.0

    • HUM 1: Review Criteria Requirements

      + Details

      The organization utilizes explicit clinical review criteria or scripts that are:

        (a) Developed with involvement from appropriate providers with current knowledge relevant to the criteria or scripts under review;
        (b) Based on current clinical principles and processes;
        (c) Evaluated at least annually and updated if necessary by:
          (i) The organization itself; and
          (ii) Appropriate, actively practicing physicians and other providers with current knowledge relevant to the criteria or scripts under review; and
        (d) Approved by the medical director (or equivalent designate) or clinical director (or equivalent designate).

       

      Question: Our organization references commercial utilization management clinical criteria for accredited HUM Programs, as mandated by the client/contract. Please explain what the outcome should be regarding the medical/clinical director and other physicians (including outside providers) review to verify their continued appropriateness? If commercial criteria is required by the contract, what should the medical/clinical director review for - what should the outcome of their review include? 

      If this is commercial, and standardized criteria, how/what should be reviewed, and what is the desired outcome?

      Also, contracts may require "supplemental" clinical criteria (typically criteria that is not available for reference in the commercial criteria). This supplemental criteria has been established by the client and mandated for use. Again, what should the medical/clinical director review for, and what should the outcome of their review be, given that this criteria was mandated for use by the client?

      Response: HUM 1 requires review of the medical necessity criteria used for four purposes: (1) development by appropriate providers and prescribers per element a of the standard and annual update and review by actively practicing providers; appropriateness to your business model; appropriateness for application to the population for which it is being used; and continued consistency with current standards of care [see element (b) of the standard]. As medical knowledge changes rapidly these days, the last is very important to assure that your organization is not being required to apply out-dated criteria to medical necessity determinations. Continuing appropriateness for the member population should be assured as well as the characteristics of the member group may change over time. Your medical director may rely on information obtained from your client(s) re: development and annual review procedures that they follow. You need not duplicate any reviews of which you are assured by your client(s). But elements (a), (b) & (c) of the standard must be specifically addressed and documented for your medical director to comply with element (d).

    • HUM 7: Limitations in Use of Non-Clinical Staff

      + Details

      For initial screening, the organization limits use of non-clinical administrative staff to:

        (a) Performance of review of service request for completeness of information;
        (b) Collection and transfer of non-clinical data;
        (c) Acquisition of structured clinical data; and
        (d) Activities that do not require evaluation or interpretation of clinical information.

       

      Question: Can a licensed pharmacy technician functioning in an intake/screening role make certification decisions as long as the organization provides specific criteria, scripted guidelines and the staff do not require the staff to interpret clinical information and also have nurses/physicians directly available to support them if any questions, need guidance? 

      If the pharmacy tech can not approve the request they would send to an initial clinical reviewer and/or peer reviewer and the pharm tech staff would also have clinical resource staff available. We currently do not have pharm techs certify requests but other accredited organizations due and appears to be allowable in the pharmacy accreditations. It appears we could expand their role and PhT licensure for approvals. Thank you for your input.

      Response: The current version of the Accreditation Guide for HUM v 7.2 contains newer interpretive information regarding Pharmacy Tech qualifications to perform initial clinical review. It reads: "For drug utilization management review, adequately trained pharmacy technicians are acceptable for conducting initial clinical review provided they work under the supervision of a pharmacist or are acting within the scope of algorithms. ... Pharmacy technicians are individuals who are either licensed or certified in accordance with the state where they are practicing, or they have been adequately trained. “Adequately trained” means that the individual has been part of an extensive training program and/or has had significant experience at a dispensing site. If pharmacy technicians are conducting reviews, they must be certified licensed in accordance with the state where they are practicing if the state requires it. Adequately trained pharmacy technicians are acceptable for conducting the review provided they work under the supervision of a pharmacist or are acting within the scope of algorithms. For non-automated review, pharmacy technicians may not issue clinical non-certifications." Although your accreditation is under v 7.0 it is acceptable for your organization to adopt this newer interpretation now and to permit Pharmacy Technicians to approve drug authorizations.

    • HUM 14: Peer Clinical Reviewer Qualifications

      + Details

      Individuals who conduct peer clinical review are clinical peers who:

        (a) Hold an active, unrestricted license or certification to practice medicine or a health profession in a state or territory of the United States;
        (b) Unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting a peer clinical review;
        (c) Are qualified, as determined by the medical director or clinical director, to render a clinical opinion about the medical condition, procedures, and treatment under review; and
        (d) Hold a current and valid license:
          (i) In the same licensure category as the ordering provider; or
          (ii) As a doctor of medicine or doctor of osteopathic medicine.

       

      Question: This question recently came up in regards to the URAC Standard on Peer Clinical Reviewer Qualifications, and we would appreciate some guidance on the standard HUM14: Peer Clinical Reviewer Qualifications:

      Individuals who conduct peer clinical review are clinical peers who:
        a. Hold an active, unrestricted license to practice medicine or a health profession in a state or territory of the United States
        b. Unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting a peer clinical review
        c. Are qualified, as determined by the medical director or clinical director, to render clinical opinion about the medical condition, procedures, and treatment under review
        d. Hold a current and valid license
        a. In the same licensure category as the ordering provider, or 
        b. As a doctor of medicine or doctor of osteopathic medicine.

      As a national UR agent, our organization has a number of Peer Clinical Reviewers that are licensed in multiple states. HUM 14 (a) and (d) refers to “an active unrestricted license” as a requirement. 

      • Question: If a Peer Clinical Reviewer is licensed in multiple states and becomes restricted or limited in one state, but remains active and without restriction in the others – should our organization interpret this as the practitioner being restricted from issuing medical necessity determinations – for all states?

      We would appreciate your assistance in the interpretation of this standard, as it relates to Peer Clinical Reviewers with multiple licenses.

      Response: HUM 14 is interpreted by organizations based on the locations where they do business. So, often that leads them to require that peer reviewers be licensed in the state where the organization is located. As you probably know, some states do require same-state licensure for peer reviewers and accredited organizations are expected to adhere to those laws and regulations when doing reviews in those states. That said, there is no specific URAC rule that addresses the situation where one of multiple licenses becomes restricted. URAC does expect that an accredited organization would make a carefully considered decision about the implications of the restriction. In accordance with HUM 14(c) your medical director must investigate and determine whether the cause and nature of the restriction is limiting to the ability to perform credible reviews in other states. Note that HUM 14(c) is a mandatory element. The practitioner would, of course, be prohibited from performing reviews in the jurisdiction of the restricted license since that would be out of compliance with HUM 14(a). Note that HUM 14(a) is a mandatory standard required for full accreditation status.

    • HUM 17: Prospective Review Time Frames

      + Details

      For prospective review, the organization issues a determination:

        (a) As soon as possible based on the clinical situation, but in no case later than 72 hours of the receipt of request for a utilization management determination, if it is a case involving urgent care; or
        (b) Within 15 calendar days of the receipt of request for a utilization management determination, if it is a non-urgent case; and
        (c) For non-urgent cases, this period may be extended one time by the organization for up to 15 calendar days:
          (i) Provided that the organization determines that an extension is necessary because of matters beyond the control of the organization; and
          (ii) Notifies the patient, prior to the expiration of the initial 15 calendar day period, of the circumstances requiring the extension and the date when the plan expects to make a decision; and
          (iii) If a patient fails to submit necessary information to decide the case, the notice of extension must specifically describe the required information and the patient must be given at least 45 calendar days from receipt of notice to respond to the plan request for more information.

       

      Question: I have a clarifying question regarding URAC Standard HUM 18- Retrospective Review Time Frames.

      The Interpretive Information says that in cases where there is an extension to obtain additional information to consider the case- URAC will consider the URAC time frames suspended during the extension.

      Does this mean, if our plan requests an extension so we can obtain additional clinical documentation, that the 30 day clock is suspended? If so, once the clinical documentation is received does the 30 day time frame start over at that time or does it continue to be suspended and we have no time limit to complete the retrospective review?

      Response: You are correct that when a health plan requests additional information the clock on prospective (HUM 17) or retrospective (HUM 18) reviews pauses for the period of time required to obtain the information requested. So, once the information is received, then the clock resumes where it was paused. For situations in which the information is not received, we recommend that organizations have policies and procedures about how long they wait and what procedures are appropriate for bringing the review process to a close.

    • HUM 18: Retrospective Review Time Frames

      + Details

      For retrospective review, the organization issues a determination:

        (a) Within 30 calendar days of the receipt of request for a utilization management determination; and
        (b) This period may be extended one time by the organization for up to 15 calendar days:
          (i) Provided that the organization determines that an extension is necessary because of matters beyond the control of the organization; and
          (ii) Notifies the patient, prior to the expiration of the initial 30 calendar day period, of the circumstances requiring the extension and the date when the plan expects to make a decision; and
          (iii) If a patient fails to submit necessary information to decide the case, the notice of extension must specifically describe the required information and the patient must be given at least 45 calendar days from receipt of notice to respond to the plan request for more information.

       

      Question: This standard and other HUM standards have onsite review materials that include copies or re-prints of written notification letters. Will we need to remove protected health information or will the URAC staff sign a confidentiality agreement?

      Response: You would only need to remove PHI if a letter is non-compliant and reviewer would need the documentation to prove the non-compliance issue. The BAA already in place with URAC covers the onsite review activities.

    • HUM 19: Concurrent Review Time Frames

      + Details

      For concurrent review, the organization adheres to the following time frames:

        (a) For reductions or terminations in a previously approved course of treatment, the organization issues the determination early enough to allow the patient to request a review and receive a decision before the reduction or termination occurs; and
        (b) For requests to extend a current course of treatment, the organization issues the determination within:
          (i) 24 hours of the request for a utilization management determination, if it is a case involving urgent care and the request for extension was received at least 24 hours before the expiration of the currently certified period or treatments; or
          (ii) 72 hours of the request for a utilization management determination, if it is a case involving urgent care and the request for extension was received less than 24 hours before the expiration of the currently certified period or treatments.

       

      Question: If we have inclement weather and the health plan is closed due to same, as a delegated entity, are we held to the 72 hr turnaround time ??? (we have impending snow) if we could have an answer today, it would be great. thanks!

      Response: HUM 19 (c)(i) speaks to extensions for matters "beyond the control of the organization" for non-urgent cases. However, there is no extension provision for cases involving urgent care. We recommend that you focus on cases involving urgent care both prior to and during the pending snow storm. Many accredited organizations permit staff to conduct reviews from home during inclement weather. Also, turn to your business continuity plan to see if there is an established plan for handling business interruptions due to inclement weather. 

    • HUM 21: Continued Certification Decision Requirements

      + Details

      Confirmation of certification for continued hospitalization or services includes the number of extended days or units of service, the next anticipated review point, the new total number of days or services approved, and the date of admission or onset of services.

      Question: We are seeking clarification on handling of Concurrent Review determinations when a patient is in the hospital and the need for concurrent review is received or determined, However, NO CLINICAL is provided. Can a concurrent review be suspended in order to gather additional information such is allowed for Prospective and Retrospective reviews? If the case can be suspended, what are the requirements around such a suspension, ie. letter of suspension, etc. such as with a suspension for Prospective and Retrospective cases. Please advise specific to any types of concurrent review in which no clinical is received.

      Response: Under HUM 32 an accredited organization establishes its procedures for lack of information circumstances. Concurrent reviews are specifically included in element (a). At this point in time URAC standards do not distinguish between concurrent review and continued stay certifications. So, HUM 32(a) is applicable to all types of concurrent reviews.

    • HUM 22: Written Notice of Non-Certification Decisions and Rationale

      + Details

      For non-certifications, the organization issues written notification of the non-certification decision to the patient and attending physician or other ordering provider or facility rendering service that includes:

        (a) The principal reasons for the determination not to certify;
        (b) A statement that the clinical rationale used in making the non-certification decision will be provided, in writing, upon request; and
        (c) Instructions for:
          (i) Initiating an appeal of the non-certification; and
          (ii) Requesting a clinical rationale for the non-certification.

       

      Question: HUM 22 states the notification needs to include instructions for initiating an appeal. Do the instructions have to be listed in the letter or can there be a phone number provided and a statement to initiate an appeal please call the number provided? Thank you.

      Response: The non-certification notification required by HUM 22 that provides a phone number to call to initiate and appeal would be compliant with the standard. URAC would interpret provision of the phone number and instructions to call to initiate appeal sufficient instructions for the member and the provider should they wish to appeal.

      Question: We have been told that it might be possible to get a variance re: Safety QIP ?? We do not have members, just perform delegated UR functions. We don't have access to claims data. We are not allowed interactions with members. We have asked our delegating entity re: partnering on a QIP and that has not happened. It has been very hard for us to come up with a safety QIP. We don't have problems re: other QIPS and have several going right now.

      Response: A variance is not needed. Since you do not interface with consumers Core 24 and HUM 26 re: Patient Safety are not applicable.

    • HUM 25: Reversal of Certification Determinations

      + Details

      The organization does not reverse a certification determination unless it receives new information that is relevant to the certification and that was not available at the time of the original certification.

      Question: If an authorization is initially denied by a physician and additional information is then sent in and has new information that meets the criteria can a nurse then approve the case or does it have to be reviewed by a physician again. Thanks.

      Response: Yes, you are correct. Under HUM 12 & 13 it is appropriate for a nurse who meets the qualifications in HUM 10 to approve the authorization request when new evidence is presented that meets your organization's approved medical necessity criteria.

    • HUM 26: Prospective Review Patient Safety

      + Details

      The organization ensures that the frequency of reviews for the extension of initial determinations is based on the severity or complexity of the patient’s condition or on necessary treatment and discharge planning activity (i.e., not routinely conducted on a daily basis).

      Question: Our question is: Does URAC have requirements or standard or guidance that addresses whether an employee involved in utilization management can work from home?, OR Would working from home impact any URAC standard? Thank you.

      Response: Nothing in the URAC standards prohibit working from home. Protections would be expected to be in place for compliance with confidentiality of PHI per Core 15 and 16. Generally, these include such things as environment requirements for security of information, rules about downloading and printing, use of computer equipment, etc. Many URAC accredited organizations do have telecommuters.

    • HUM 28: Prospective and Concurrent Review Determinations

      + Details

      For prospective review and concurrent review, the organization bases review determinations solely on the medical information obtained by the organization at the time of the review determination.

      Question: We would like to have a policy that states we will require certain clinical information before we can review a request. Is this acceptable under URAC HUM 28 and 29?

      Response: Administrative denial policies generally are outside the scope of URAC standards. However, HUM 32 (b) and (c) would apply. Note the two items in the Interpretive Information in the current version of the HUM Accreditation Guide: "For URAC accreditation, the utilization management organization may set its own time frames under this standard. However, the Department of Labor claims regulations provide specific guidance on this issue." and "If the provider submits some clinical information and indicates to the company that this is all of the information that is available, then the request must be processed in accordance with standards HUM 19, 20, and 21." We suggest that you examine the Department of Labor claims regulations before deciding how to proceed with your policy.

    • HUM 30: Lack of Information Policy and Procedures

      + Details

      The organization implements policies and procedures to address situations in which it has insufficient information to conduct a review. Such policies and procedures provide for:

        (a) Procedural time frames that are appropriate to the clinical circumstances of the review (i.e., prospective, concurrent and retrospective reviews);
        (b) Resolution of cases in which the necessary information is not provided to the organization within specified time frames; and
        (c) Processes by which the organization issues an administrative non-certification due to lack of information.

       

      Question: We are not delegated non-certification determinations. We review for medical necessity and if we can not approve, our physician reviewer writes a case report to the health plan medical director with principal reason and clinical rationale for our company recommending an adverse determination. The health plan than makes decision to approve or deny the care. HOWEVER, we receive requests that lack the minimum clinical information to make a decision. We issue a recommendation of denial due to LACK OF INFORMATION (because we can't obtain in the timeframe to complete the case) this is essential an administrative denial b/c it is not a clinical reason. Does a peer physician need to finalize those cases or can our nurses/trained non-clinical staff with scripts review and issue a recommend administrative denial for lack of information? Again, these are not clinical reasons for recommending a denial solely based Lack of information to complete a clinical review to make medical necessity determination. I want to confirm that an administrative denial by staff would not conflict with HUM 9 and HUM 12 as those are for clinical reasons. Also want to make sure this process does not require a physician peer reviewer to issue a LOI administrative denial. Thank you!

      Response: Nothing in URAC standard HUM 30 prohibits an organization from adopting policies and procedures permitting administrative denials for lack of information without a peer review. Many accredited organizations permit initial clinical review personnel such as nurses to issue administrative denials for lack of information. Some also permit non-clinical staff to use scripts and issue a denial when there is a clear lack of information or when no clinical information has been submitted by the ordering provider and attempts to obtain clinical data are unsuccessful. Whatever process is in place must be documented clearly in approved policies and procedures.

      Question: Two part question:

      1. Can an administrative denial be issued when there is NO clinical information received after attempting to obtain it?
      2. If the only clinical that is received is a diagnosis code or CPT code, can an administrative denial still be completed after failed attempts to get the clinical?

      Response: Yes to both of your questions. Administrative denials are appropriate under your lack of information policies and procedures per HUM 30 and may be issued by a nurse when clinical information is absent. It is important that the steps to be taken to implement such a policy are documented and approved by your Medical Director.

    • HUM 33: Appeal Peer Reviewer Qualifications

      + Details

      Individuals who conduct appeals considerations are clinical peers who:

        (a) Hold an active, unrestricted license or certification to practice medicine or a health profession in a state or territory of the United States;
        (b) Unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting an appeals consideration;
        (c) Are in the same profession and in a similar specialty as typically manages the medical condition, procedure, or treatment as mutually deemed appropriate;
        (d) Are neither the individual who made the original non-certification, nor the subordinate of such an individual; and
        (e) Are board-certified (if applicable) by:
          (i) A specialty board approved by the American Board of Medical Specialties (doctors of medicine); or
          (ii) The Advisory Board of Osteopathic Specialists from the major areas of clinical services (doctors of osteopathic medicine).
        (f) [Standard element is not applicable.]

       

      Question: For health plans that have two levels of internal appeal, does URAC specifically require same specialty match review of the appeal at any specific level of appeal or is that up to the discretion of the health plan to select the level of appeal to conduct the specialty match appeal peer review?

      Response: HUM 33 specifically refers to the first level appeal process. URAC standards are silent about subsequent appeals processes except those required for external review under state laws and regulations. But only the first level of appeals in within the scope of the URAC HUM standards 33 - 41 which detail the required appeals processes.

    • HUM 34: Reviewer Attestation Regarding Credentials and Knowledge

      + Details

      For each appeal case they accept, reviewers attest to:

        (a) Having a scope of licensure or certification that typically manages the medical condition, procedure, treatment, or issue under review; and
        (b) Current, relevant experience and/or knowledge to render a determination for the case under review.

       

      Question:

      1. Does the # of years for current experience have to be specified on the attestation?
      2. At the time of the URAC site visit, does a copy of the attestation form used for each appeal review need to be in the file? If the reviewer provides their initials and date on a screen which confirms their review and agreement to the attestation - is this enough? there would always be a master copy of the attestation to review.

      Response: Re: # 1 - No, the number of years of experience need not be specified in the attestation to comply with HUM 34 in version 7.0 of HUM (HUM 37 in the most current version of the standards, v 7.2). The number of years of experience is applicable in IRO standards for both internal and external reviews. 

      Re: # 2 - The attestation must be included in each file to comply with HUM 34. Compliance is audited as part of the case file review of appeals. The Accreditation Guide for HUM 34 in version 7.0 clearly states the expectation: "to demonstrate compliance with this standard, URAC expects a case by case act of attestation by the peer reviewer. Thus, if the statement at the top of the screen requires some active affirmation (such as a check box) by the peer reviewer, then it would be in compliance .... If the statement at the top of the page does not require validation by the peer reviewer, then the attestation is passive and not in compliance ...." Also, the Points to Remember add this regarding the methods of documenting the reviewer's active attestation for each case: "methods of documenting reviewer attestation include: electronic signature, wet signature, electronic or wet mark in a checkbox where the identity of the reviewer can be determined by name or using a unique identifier assigned to an individual reviewer". So, it is clear that the statement must be visible at to the reviewer at the time of signing for each case accepted for review and that each file must demonstrate an active attestation for that case.

    • Health Utilization Management Version 5.1

      • Standards 1-30: General Question

        + Details

        Question: Does URAC consider the determination of whether a treatment or service is or is not "experimental" or "investigational" to be within the scope of "utilization review" and therefore subject to its standards? Our question does not focus on whether a particular service, procedure, drug or device was or was not in benefit; our concern is with the medical evaluation of same.  When a payer makes a medical determination that a service, procedure, drug or device is "experimental" and/or "investigational" and the attending physician disagrees based upon his perspective of prevailing practice, peer reviewed literature, etc., we would classify the appeal of such "non-certification" as falling within the four corners of our state law that addresses medical determinations of the necessity and appropriateness of care, drugs and devices.  We were interested in knowing whether URAC concurred on this point.

        Response: Up to the point of requesting an appeal of the non-certification due to an initial determination that the service or treatment is experimental or investigational, the process is covered by URAC’s Health Utilization Management Standards (e.g., HUM 1 30); the subsequent appeal process is covered by URAC’s Health Plan Standards (e.g., Core 11, Core 27 29 and P UM 1) cited below.

        CORE 11 – Senior Clinical Staff Responsibilities
        The senior clinical staff person:

        1. Provides guidance for all clinical aspects of program;
        2. Is responsible for clinical aspects of program; and
        3. Has periodic consultation with practitioners in the field.

        CORE 27 – Complaint and Appeal System
        The organization maintains a system to receive and respond in a timely manner to complaints and, when appropriate, inform consumers of their rights to submit an appeal.

        CORE 28 – Appeal Process
        The organization maintains a formal appeal resolution process that includes:

        1. Written notice of final determination with an explanation of the reason for the determination;
        2. Notification of the process for seeking further review, if available; and
        3. A reasonable, specified time frame for resolution and response.

        CORE 29 – Complaint and Appeal Reporting
        The organization reports analysis of the complaints and appeals to the quality management committee.

        P-UM 1 – Independent Review Process
        The organization has a mechanism for consumers to access an independent review process, after all internal appeal mechanisms have been exhausted, for clinical determinations relating to the necessity or appropriateness of medical services (including determinations that proposed medical services are experimental in nature).  Independent review entities:

        1. Must access and rely on appropriate clinical expertise in rendering independent review determinations;
        2. Must not have any direct financial interest in the organization or in the outcome of the independent review;
        3. Render determinations:
        4. For non-urgent cases, within thirty calendar days from the date the consumer initiated the independent review; and
        5. For cases involving urgent care, within 72 hours from the date the consumer initiated the independent review;
        6. May not have been involved in the original determination under appeal.
      • Standard 10: Initial Clinical Reviewer Qualifications

        + Details

        Individuals who conduct initial clinical review:

        1. Are appropriate health professionals; and
        2. Possess an active professional relevant license.

        Question: Does the URAC Health UM, CM and DM accreditation include staff performing these functions that are telecommuting or working out of a client site?

        Response: Yes, staff working offsite – either telecommuting or working at a client site – is included within the scope of the accreditation. URAC reviewers will examine staff files, QM oversight, etc. as it involves this type of staff and URAC reviewers may interview them either telephonically, have them come into the office, or even visit them at their off-site location.
      • Standards 15 & 16: Peer-to-Peer Conversation Availability and Peer-to-Peer Conversation Alternate

        + Details

        HUM 15 – Peer-to-Peer Conversation Availability
        Health professionals that conduct peer clinical review are available to discuss review determinations with attending physicians or other ordering providers.

        Question: As the purpose of peer to peer is to avert a denial (rather than to argue about one after a decision has been made), is it acceptable for a firm to inform providers and patients of the right to peer to peer as a part of the initial determination and/or appeal, and to NOT provide peer to peer AFTER the decision has been rendered and communicated so long as documentation/proof of offering peer to peer and the provider/patient not accepting the offer is in the record?

        Further, is it acceptable under the standards to hold provider/treating physicians to a timeframe of completing the peer to peer that allows the firm to render their decision within 29CFR2560 timeframes and should treating provider fail to complete the peer to peer within the designated timeframe to NOT provide peer to peer after the decision has been rendered/until the appeal process has been initiated.

        In other words - when we receive clinical information that does not result in the front line staff member being able to certify the request, we inform the requestor that the case is being sent to Physician review for determination and we encourage them to avail themselves of the opportunity for peer to peer so that their physician can discuss the case with the reviewing physician. In instances where they fail to avail themselves of that opportunity, or fail to comply within the timeframe that keeps us in compliance with 29CFR2560 (we DO inform them of the deadline in advance), we explain that the purpose of peer to peer is to avoid denial, not to argue about one after it has been rendered and that while they MAY speak with the reviewing physician, he is NOT allowed to reverse the decision that has been rendered. They MUST utilize the appeals process as specified by their plan if they wish for the determination to be reconsidered and the decision possibly changed.

        We do this because of OCR concerns, we want all members of the plan to be treated fairly and equitably, all having the opportunity for peer to peer to avert denial, and none having a higher number of reviews/determinations than what the SPD of the plan allows.

        Response: URAC HUM standards certainly permit peer-to-peer conversations to be held prior to making a determination. In fact, many accredited organizations do reach out actively to providers in order to obtain the most complete information about the authorization request and thus avoid appeals. However, HUM 18 does state specifically: "When a determination is made to issue a non-certification and no peer-to-peer conversation has occurred: (a) The organization provides, within one business day of a request by the attending physician or ordering provider, the opportunity to discuss the non-certification decision". The sub-elements are both weighted "4". So, failure to permit providers from requesting a peer-to-peer after the determination but prior to an appeal would not be compliant with HUM 18 (a). The noncompliance would result in loss of 4 points toward a Full Accreditation score calculation.

        HUM 16 – Peer-to-Peer Conversation Alternate
        When a determination is made to issue a non-certification and no peer-to-peer conversation has occurred:

        1. The organization provides, within one business day of a request by the attending physician or ordering provider, the opportunity to discuss the non-certification decision:
        2. With the clinical peer reviewer making the initial determination; or
        3. With a different clinical peer, if the original clinical peer reviewer cannot be available within one business day); and
        4. If a peer-to-peer conversation or review of additional information does not result in a certification, the organization informs the provider and consumer of the right to initiate an appeal and the procedure to do so.

        Question: Does URAC require the offering of a peer-to-peer conversation for retrospective medical necessity denials?

        Response: No, standards HUM 15 and HUM 16 apply to the prospective and concurrent review processes where the request for certification is non-certified by a clinical peer reviewer.
      • Standard 31: Appeals Process

        + Details

        As part of the appeals process:

        1. The organization provides the patient, provider, or facility rendering service the opportunity to submit written comments, documents, records, and other information relating to the case, and
        2. Takes all such information into account during the appeals process without regard to whether such information was submitted or considered in the initial consideration of the case, and
        3. In instance of a first level appeal, the organization implements the decision of the first level clinical appeal if it overturns the initial denial.

        Definition of Appeal:  Formal request for review of an organizational determination (i.e., services have been denied, reduced, etc.)  Note: Specific terms used to describe appeals vary, and are often determined by law or regulation. URAC’s UM Standards apply to first-level appeal.

        Question: Is the UM appeal file review limited to first level appeal, or does it include all levels of appeals?

        Response: The scope of URAC’s medical necessity appeal process is limited to the first level of review as indicated by the definition (above) and standard HUM 31(c) (above); therefore, the file review for Health Utilization Management accreditation will be limited to the first level of review.
      • Standard 32: Appeal Peer Reviewer Qualifications

        + Details

        Appeals considerations are conducted by health professionals who:

        1. Are clinical peers;
        2. Hold an active, unrestricted license to practice medicine or a health profession;
        3. Are board-certified (if applicable) by:
        4. A specialty board approved by the American Board of  Medical Specialties (doctors of medicine); or
        5. The Advisory Board of Osteopathic Specialists from the major areas of clinical services (doctors of osteopathic medicine);
        6. Are in the same profession and in a similar specialty as typically manages the medical condition, procedure, or treatment as mutually deemed appropriate; and
        7. Are neither the individual who made the original non-certification, nor the subordinate of such an individual.

        Question: If new information is received with an appeal request, can a nurse reviewer approve the appeal if the new information meets criteria?

        Response: Yes.  Though this process is not specifically addressed in the accreditation guide, it is not prohibited by the standards.  An organization must meet the timeframes required by the standards regardless of any additional steps it may conduct.

        Question: What is appropriate specialty matching and does the standard of care in a community factor in?  For instance, in our community we have no endocrinologists so our PCPs generally care for their own diabetic patients, but if that patient is in a teaching facility they might be cared for by an Endo.  If there is an appeal by a specialist for a condition, which is generally treated locally by a PCP, who would URAC like to see reviewing the appeal?

        Response: When selecting a physician to conduct a medical necessity appeal, first choice would be a specialist in the area of concern for the appeal, even if the physician requesting the appeal is not a specialist.  Physicians with more general practices (e.g., IM, PCP, FP, etc.) may conduct an appeal if they have experience treating the case under review.  When asked to do a review, physicians will tell you if it is not an area they typically treat, in which case you would select another physician to conduct the appeal.  Also, pursuant to the standard, the selected appeal reviewer is “…mutually deemed appropriate” by your organization and the physician requesting the appeal [HUM 32(d)].  So if there is some doubt, it is perfectly acceptable to discuss the selection with the requesting provider.  Also, general practitioners are not used for appeals and it is not appropriate to have a pediatrician review an adult case.

        If an endocrinologist or a PCP is managing a diabetic case and has made an appeal, then an endocrinologist would be first choice to conduct the appeal, an IM or PCP with extensive experience in diabetes would be a second choice.  See additional scenarios below.

        Scenario 2: Cardiothoracic surgeon performs CABG, patient is newly diagnosed with Diabetes, Endo was consulted and discharge left up to Endo.  Last day was denied and is being appealed.  What kind of specialist should review?  Endo, IM, FP or GP or Cardiothoracic surgeon?

        Response: The issue keeping the patient in the hospital was diabetes, so an endocrinologist would review the appeal for the last day of inpatient stay, or IM/FP with extensive experience in diabetes.  General practitioners are typically not used for appeals.

        Scenario 3: Pt. was admitted for Chest pain by IM/GP/FP.  Cardiology was consulted. Discharge by attending left up to consultant.  Day denied and appealed.  Who reviews, Cardiology or IM/ FP/GP?

        Response: Medical issue could be reviewed by IM/FP or a cardiologist.  General practitioners are typically not used for appeals.

        Scenario 4: Pt admitted with new onset of seizures by IM/FP/GP/Peds.  Neuro consult ordered.  Discharge by attending left up to consultant.  Day denied and appealed.  Who reviews, Neuro or IM/FP/GP/Peds?

        Response: Neurologist would conduct the appeal since seizures were the reason for the last inpatient day.  If it was a pediatric patient with seizures, then a pediatrician with experience treating those types of patients could conduct the appeal.

        Scenario 5: Can FP review for IM for inpatient appeals or does it have to be IM for IM and FP for FP, etc. 

        Response: Internal Medicine should review for Internal Medicine, FP for FP.

        Scenario 6: Does the matching have to be MD to MD or can it be MD reviewed by DO, etc?

        Response: MD and DO can review for each other.

        Scenario 7: Can a general surgeon review a case of a Vascular surgeon?

        Response: Did the appeal turn on a vascular issue – such as was the vascular surgery necessary?  If yes, then a vascular surgeon would be appropriate to conduct the appeal.  If more of a general surgical issue, then a general surgeon could review the case.

        Scenario 8: Do the reviewers just have to have knowledge in the field or truly be "specialty matched"?

        Response: Start with the specialty match – you can’t go wrong there.  Then there are general surgeons and internal medicine where they may have extensive experience in a given area, and as such could be used for the appeal.

        Scenario 9: IM admits for DVT.  An inpatient day is denied.  Who can review the appeal?  FP or Peds or does it have to be IM?

        Response: IM would be best choice; PCP/FP could be used.  Most primary care doctors will tell you if they do not believe they have the background or experience to review a case.  Peds is not a good choice for adult cases.

        Scenario 10: FP admits an adult with Pneumonia.  Day is denied.  Can a Pediatrician review?  Must it be FP?  IM?

        Response: Pediatrician is not appropriate for an appeal on an adult case.  FP or IM could review the case.

        Scenario 11: A 10-wk pregnant patient admitted with DVT by OB.  Vascular surgeon consults and follows, too.  Who can review case for denied days?  Can FP or Pediatrician review concurrently without consulting with a Like Specialist for advice?

        Response: It depends upon the reason for the denial and why patient was kept – was there some other reason for the hospital stay?  If it was determined that the DVT condition no longer warranted inpatient stay, then a vascular surgeon, IM or FP could review.  If there was some other complication related to the pregnancy, then an OB would appear to be appropriate.

        Scenario 12: Total abdominal hysterectomy performed by GYN surgeon.  Can general surgeon do the appeal review?

        Response: If the general surgeon has experience with abdominal hysterectomies, then yes.

        Scenario 13: Pulmonologist admits for pulmonary emboli.  Who must review appeal?  IM, FP, Peds or pulmonologist?

        Response: Pulmonologist, IM or FP.  Peds should review for pediatric patients.

        Scenario 14: Pancreatitis admitted by FP.  Consulted with a general surgeon, but treated medically.  Who should review appeal?

        Response: IM or FP.

        Scenario 15: GI hemorrhage admitted by GE.  No surgery was required, just scoping and watching. Who should review appeal?  GE, surgeon, IM, FP, Peds?

        Response: GE, surgeon or IM.  FP if experience with these types of cases.  Peds should not review adult cases.

        Scenario 16: Can a Pediatrician review cases on adults that were admitted by IM or FP or specialists?  Can FP do reviews on neonates being cared for by neonatologists?

        Response: No to both scenarios.

      HIPAA Security Version 3.0

      • Standard HS1: Security Official

        + Details

        The organization has documented appointment of a chief security official who has defined authority, oversight, and accountability, and who is responsible for the HIPAA security compliance program of the organization, including the development of any necessary policies and procedures.

        Question: What type of preparation is required in order to become a "security official" for HIPAA matters?

        Response: URAC outlines the requirements in the "Points to Remember" section of the accreditation guide for version 3.0 of these standards.  In summary, two (2) years managing a HIPAA Security compliance program or greater than one (1) year's experience with significant responsibility for regulatory compliance AND certification in HIPAA Security AND any other industry-recognized security certification.  The certification is chosen by the applicant organization and must meet URAC's definition for "certification."  (URAC does not keep a list of approved certifications; instead, as part of its desktop review documentation, the organization includes information demonstrating that the certification chosen meets URAC's definition.)

      • Standard 8: Policy and Procedure Updates

        + Details

        The organization:

        1. Revises policies and procedures as necessary, prior to:
        2. Environmental or operational changes affecting the security of the electronic protected health information based upon information from periodic risk assessment;
        3. The effective date for changes in the HIPAA Security Rule;
        4. The effective date for law or regulation affecting the HIPAA Privacy Rule; and
        5. URAC application for HIPAA Security Accreditation to the organization; and
        6. Maintains an archive of superseded policies and procedures for at least six (6) years.

        Question: Why was this standard revised from the previous version (2.1)?

        Response: Some applicant organizations are reactive rather than proactive about updating their policies and procedures as needed to reflect changes to their own processes or the HIPAA Security Rule; therefore, this change was made to clarify the intent of the standard as well as in response to the sections of the American Reinvestment and Recovery Act (ARRA) that impact the HIPAA Security Rule, which are now considered part of the HIPAA Security Rule.

        The specific section of the HITECH Act that supports this standard generally and specifically is as follows: ARRA Pub.L. 111-5, Title Xiii Subsection D.

      HIPAA Privacy Version 3.0

      • General Question

        + Details

        Question: Why were the HIPAA Privacy standards for business associates and covered entities combined into one (1) accreditation?

        Response: Some business associate applicant organizations do not identify all parts of the HIPAA Privacy Rule that are applicable to them, resulting in noncompliance with the Rule as well as the concomitant URAC standard(s) for accreditation.  By having to address each standard, the business applicant must affirmatively evaluate whether it is required to meet each particular standard and document why the particular standard does not apply to their organization.

      • Standard HP1: Privacy Official

        + Details

        Question: What type of preparation is required in order to become a "privacy official" for HIPAA matters? 

        Response: URAC outlines the requirements in the "Points to Remember" section of the accreditation guide for version 3.0 of these standards.  In summary, two (2) years managing a HIPAA Privacy compliance program or greater than one (1) years' experience with significant responsibility for regulatory compliance AND certification in HIPAA Privacy AND any other industry-recognized security certification.  The certification is chosen by the applicant organization and must meet URAC's definition for "certification."  (URAC does not keep a list of approved certifications; instead, as part of its desktop review documentation, the organization includes information demonstrating that the certification chosen meets URAC's definition.)

      • Standard HP9: Policy and Procedure Updates

        + Details

        Question: Why was this standard revised from the previous version (2.1)?

        Response: Some applicant organizations are reactive rather than proactive about updating their policies and procedures as needed to reflect changes to their own processes or the HIPAA Privacy Rule; therefore, this change was made to clarify the intent of the standard as well as in response to the sections of the American Reinvestment and Recovery Act (ARRA)/HITECH that impact the HIPAA Privacy Rule, which are now considered part of the HIPAA Privacy Rule. The specific section of the HITECH Act that supports this standard generally and specifically is as follows: ARRA Pub.L. 111-5, Title Xiii Subsection D.

      • Standard HP26: Access and Amendment

        + Details

        The organization may specify exceptions when it will not release or allow amendment of protected health information, provided that such exceptions are consistent with the HIPAA Privacy Rule.

        The organization has policies and procedures to:

        1. Accept and process requests by individuals to inspect and copy their protected health information that is maintained in a designated record set;
        2. Allow individuals to request amendments of their protected health information in a designated record set;
        3. Offer individuals an electronic copy of their information contained within a designated record set, which is maintained within an electronic health record and contains disclosures made for Treatment, Payment and Operations (TPO); and
        4. Offer to forward an electronic copy of individuals' information contained within a designated record set, which is maintained within an electronic health record to a third party of their choice.  This electronic copy of the information maintained within the electronic health record must contain disclosures made for Treatment, Payment and Operations (TPO).

        Question : Why do organizations have to offer individuals an electronic copy of their information?

        Response: The HITECH Act requires organizations to offer individuals an electronic copy of information available within a designated record set. 

      • Standard HP 55: Nominal Reimbursement Providing PHI for Marketing

        + Details

        Under no circumstances shall the organization accept more than a nominal amount of financial reimbursement for providing protected health information to another entity for use in marketing.

        Question : Why was this standard added to the HIPAA Privacy standards (v3.0) and how will URAC evaluate "nominal" reimbursement?

        Response: The standard reflects a requirement under the HITECH Act and though "nominal" is not specifically defined URAC will examine a breakdown of the organization's charges for providing the protected information to another entity that seeks to use it for marketing purposes.  The breakdown must include how much it cost the organization to provide the information, apart from any other charges.  Evidence must be provided upon desktop review.

      • Standard HP 56: Authorization to Use PHI for Fundraising

        + Details

        If the organization uses protected health information for fundraising purposes, it has policies and procedures that govern such activities and that specify the circumstances under which it will seek authorization, whereby:

        1. Individuals must indicate on the authorization form that they are aware of their right to "opt in" and the process for doing so, of authorizing the use of their protected health information for such fundraising purposes; and [M]
        2. If the organization does not use protected health information for fundraising purposes, then it must have a policy statement to that effect. [M]

        Question: Doesn't the new Privacy Rule call for individuals to "opt out" instead of "opt in" for the authorizing the use of their personal health information (PHI) for fundraising?

        Response: A HIPAA Privacy Rule change requires that individuals are provided a clear opportunity to "opt out" of authorizing use of their PHI for fundraising purposes.  URAC chose to employ a more consumer-centric standard by requiring that an individual must "opt in" instead of "opt out" as part of the formal authorization process for using PHI in fundraising.

      • Standard HPRV 13: Privacy Awareness Training

        + Details

        Question: Why are the topics of civil and criminal penalties included in privacy training requirements?

        Response: The Privacy provisions outlined in President Obama's economic stimulus package, the "American Recovery and Reinvestment Act" (ARRA)/HITECH include civil and criminal penalties which require organizations to provide training on the various penalties, the fine amount and under what circumstances they apply.  In addition, ARRA/HITECH has specific guidelines expanding the enforcement powers of State Attorneys General. Under the regulations, State Attorneys General may work on behalf of state's residents to bring civil actions, stop violations, or obtain damages. Although state action is limited while federal action is pending.  This now applies to all covered entities, business associates and individuals, with access to private patient information.

      • Standard HPRV 15: Breach Discovery Policy

        + Details

        Question: Under what circumstances does the "Breach Discovery Policy" apply?

        Response: This standard applies to all situations where it is suspected that a breach might have occurred, which is the initial stage when the organization has an incident that may affect the privacy and/or security of PHI and/or ePHI and may not be sure whether a breach has actually occurred or not.

      • Standard HPRV 18: Breach Notification to the Federal Government

        + Details

        Question: Does this standard apply if the organization determines that a breach did not occur?

        Response: No, notification to the Department of Health and Human Services is not required if a breach did not occur.

      • Standard HPRV 21: Post-Breach Evaluation and Remediation

        + Details

        Question: What happens if the same breach occurs more than once?

        Response: URAC will review the organization's post-breach evaluation and remediation process to determine that it was done pursuant to the standard in each instance.

      • Standard HPRV 67: Privacy Notice Provision

        + Details

        Question: The standard regarding notice to subscribers of privacy practices seems to contradict the HIPAA regulation.  How do you explain that?  How are organizations to provide this notice?

        Response: Standard HPRV 67 "Privacy Notice Provision" is consistent with HIPAA regulation; however, it is more stringent.  Though it is impractical to provide "Notice of Privacy Practices" to all subscribers at the time of enrollment (not just new ones), organizations need to provide notice upon material change and at least every two (2) years in order to keep its membership informed.  So HPCE 59(b) was added and requires notice of privacy practices to all subscribers at least every two (2) years.  Organizations can use mass mailings, newsletters, member Web sites, etc., as ways to carry out this notice.

      Independent Review Organization Version 5.0

      • Standard 2: Reviewer Credentials Verification

        + Details

        At a minimum, the reviewer credentialing program shall address verification of professional credentials, including:

        1. Primary source verification of the requisite licensure or certification required for clinical practice;
        2. If a reviewer is an M.D., D.O. or D.P.M and is board certified, then primary source verification of the reviewer's board certification(s);
        3. History of sanctions and/or disciplinary actions; and
        4. Professional experience including:
          1. Length of time providing direct patient care; and
          2. Dates indicating when the direct patient care occurred.
        5. Identifying a reviewer's professional affiliation, privileging or participation with:
        6. Health benefit plans of insurance issuersor group health plans; and Facilities.

        Question: What's the difference between the "certification" noted in standard element (a) and the "board certification" cited in element (b)?

        Response: The certification identified in (a) is required for entry level into clinical practice for those clinicians where certification and not a license is needed to practice.  The "board certification" in (b) is in addition to initial licensure.

      • Standard 6: External Review: Additional Reviewer Qualifications

        + Details

        Per IR 1(a), the organization establishes criteria for the qualification of reviewers.  At a minimum, such criteria will specify that for all external review cases the organization selects reviewers who:

        1. Meet the requirements as specified in IR 4;
        2. Meet the requirements as specified in IR 5;
        3. Have at least five (5) years full-time equivalent experience providing direct clinical care to patients; and
        4. Have clinical experience within the past three (3) years.

        Question: Why does IR 6 reference standards IR 4 and IR 5 when those credentials requirements are specific to internal reviews (health plan controlled) and IR 6 is specific to external reviews (required by state/federal law/regulation)?

        Response: The requirements for IR 6 build upon the credentials requirements specified in the previous standards.  So in order to avoid confusion and show the progression of requirements, the standards are cross-referenced within IR 6.
      • Standard 7: Defining Reviewer Conflict of Interest

        + Details

        Prior to executing a contract to provide review services, the organization verifies what constitutes reviewer conflict of interest according to applicable state or federal law or regulation as well as the contracting entity, including clarification of the following situations with regards to conflict of interest:

        1. A reviewer has a contract to provide health care services to enrollees of a health benefit plan of an insurance issuer or group health plan that is the subject of a review; and
        2. A reviewer has staff privileges at a facility where the recommended health care service or treatment would be provided if the health carrier's previous non-certification is reversed.

        Question: If discussions with an entity result in having (a) and/or (b) identified as a conflict of interest, then does this have to show up in the contract language and what about the reviewer conflict of interest attestation signed by each reviewer who accepts a case?

        Response: Whether or not (a) and/or (b) are identified as conflicts of interest, it's a best practice to document that decision in one place tied to the contract, which includes:

        1. The body of the contract
        2. Addendum to the contract
        3. Document/reference cited by reference within the contract

        If (a) or (b) are determined to be conflicts of interest by the parties to the contract (i.e., the IRO and organization it is contracting to provide services for), then 1. and/or 2. must be written into the reviewer conflict of interest attestation signed by the reviewers that accept the cases for that particular client.

      • Standard 12: External Review: Defining Organizational Conflict of Interest

        + Details

        Prior to executing a contract to provide external review services, the organization verifies what constitutes an organizational conflict of interest:

        • According to applicable state or federal law or regulation;
        • According to the contracting entity; and
        • Including clarification whether a relationship between the organization and an insurance issuer's or group health plan's parent company, sister companies or subsidiaries constitutes an organizational conflict of interest.

        Question: As with IR 7, if discussions with an entity result in having (a), (b) and/or (c) identified as a conflict of interest, then does this have to show up in the contract language and what about the organizational conflict of interest attestation executed prior to or as part of contracting to conduct external reviews?

        Response: Whether or not (a), (b) and/or (c) are identified as conflicts of interest, it's a best practice to document these decisions in one place tied to the contract, which includes:

        • The body of the contract;
        • Addendum to the contract; or
        • Document/reference cited by reference within the contract.

        If (a), (b) or (c) are determined to be conflicts of interest by the parties to the contract (i.e., the IRO and organization it is contracting to provide services for), then (a), (b) and/or (c) must be written into the organizational conflict of interest attestation signed by a principle of the IRO prior to executing a contract with that particular client.  It is also considered a best practice to periodically (i.e., annually) "refresh" this attestation since changes could occur that add or remove a conflict of interest for the IRO.

      • Standard 22: Time Frames for External Reviews

        + Details

        The organization completes an external review according to the following time frames (unless superseded by applicable law or regulations):

        1. An expedited review is completed as soon as possible, but in no event more than 72 hours after receipt of the request for an expedited external review;
        2. A non-expedited review is completed within 45 calendar days after receipt of the request for an external review; and
        3. The time frame starts upon receipt of the request for a review and ends once the organization issues a determination to all requisite parties as required by contract, law or regulation.

        Question: How did URAC determine the time frames for conducting a review?

        Response: The time frames align with federal requirements pursuant to the PPACA, Public Law 111 148 "Technical Release" on August 23, 2010, which indicates that a health plan must comply with the state process if it provides for an external review process that meets, at a minimum, the consumer protections set forth in the interim final regulations.

      Pharmacy Benefit Management (PBM) Version 2.0

      • General Question: PBM Organization Function

        + Details

        Question: What do pharmacy benefit management (PBM) organizations do?

        Response: Pharmacy benefit management organizations work like a health plan for drugs/medications. They manage drug benefits on behalf of employers, negotiating preferred pricing for drugs, determining pharmacy networks, and developing and maintaining a “formulary”—the list of covered or preferred medications--with the goal of helping purchasers reduce costs. They can either work in partnership with a health plan to provide services, or can work as a stand-alone service. Employers use these services to lower costs because the cost of pharmaceuticals represents more than 12 percent of total health spending, a significant proportion of their total health expenditure.

      • Standard CSCD 6 and DTM 15: Coordination of Communications

        + Details

        Question: Is an organization required to coordinate its communications with its clients’ health and service offerings?

        Response: No. The organization should ensure that the various communications received by consumers from different sources do not conflict with one another. Examples of such communications include but not limited to educational materials, information, resources, and other communications that are available to consumers. If an organization is asked to coordinate its program into the current benefit structure, it will also be necessary to coordinate materials and communications between the organization and those other existing programs. It is the purchaser’s responsibility to inform the organization of its benefit structure and request the organization coordinate its offering within that structure.

      • Standard CSCD 7: Disclosure, and CSCD 8: Disclosure Verification

        + Details

        Question: What has been revised in version 2.0 regarding these standards that address disclosure of information to clients?

        Response: These standards and elements are now mandatory, based on the new scoring methodology. The standards addresses disclosure of potential conflicts of interest, sources of revenue, pricing structure, and delegation/subcontracting. The organization allows its client to verify such disclosures.

      • Standard CSCD 14: Electronic Prescribing

        + Details

        Question: What is required by a pharmacy organization regarding electronic prescribing?

        Response: The new standard for electronic prescribing is a mandatory standard that requires the organization to use a system for electronic prescribing, which can be integrated with its drug management systems and complies with NCPDP standard transactions. The electronic prescribing system may include but not limited to information on formularies, benefits, medication history, and prescription fill status.

      • Standard PHARM-DC 9: Distribution Channel Management

        + Details

        Question: Is the PBM expected to verify the credentials of all pharmacies in its network?

        Response: Yes. With this new mandatory standard, an organization is required to have a policy and/or documented procedure for verifying its network pharmacy’s credentials. The verification must include facility state licensure, DEA registration, and professional liability insurance. The organization must also verify the determination of the absence of government debarment and the ability to transmit transactions electronically.

      Pharmacy Quality Management® Programs: General Questions

      • Accreditation Benefits

        + Details

        Question: Why is URAC’s Pharmacy Quality Management® Accreditation a good idea?

        Response: The lion’s share of insured Americans receive PBM services, yet URAC’s accreditation program is the first to give comprehensive, third-party assurance for consumers and purchasers that quality standards were met for consumer protection and empowerment, appropriate access to drugs and pharmacies, patient safety, and disclosure of pricing and contracting terms.

        In 2005 alone, Americans spent more than $170 billion for prescriptions at retail pharmacies.  This staggering dollar figure represents more than 3.1 billion individual retail prescriptions filled or re-filled—and doesn’t include some 244 million prescriptions filled via mail order pharmacy. 

        Some 70 percent of those prescription drug transactions were managed by a prescription benefit management (PBM) program.

        Pharmacy related expenses in the United States were expected to reach $250 billion in 2006, representing an 11.5 percent increase over 2005. 

        The sector saw rapid expansion with the introduction of Medicare Part D prescription drug coverage in 2006, with more than 39 million Medicare beneficiaries (90 percent) now enrolled in that program.

        The need for additional consumer protection and safety guidelines is an area of concern for many. The final rule implementing the Medicare Modernization Act of 2003 (MMA) included specific language addressing some of the key issues surrounding PBM practices, and included an invitation from the Centers for Medicare and Medicaid Services (CMS) for industry self-regulation. The regulation recognizes third party accreditation programs to create recognition for:

        • Access to covered Part D drugs including the pharmacy access requirements and the use of standardized technology and formulary requirements;
        • Drug utilization management, Quality Assurance, Medication Therapy Management, and a program to control fraud, waste and abuse; and
        • Confidentiality and accuracy of enrollee records.

        URAC’s Pharmacy Benefit Management Accreditation addresses many of these concerns.

        Question: In what ways do Pharmacy Quality Management ® organizations benefit from URAC accreditation?

        Response: The standards support creation and maintenance of a quality management framework, or a template for policies and procedures that address:

        • Ongoing management of quality procedures, including a quality committee, following a logical blueprint for quality management, maintenance and reporting.
        • Development and maintenance of written policies and procedures
        • Staff qualifications, credentialing, and oversight requirements of qualified staff for certain functions
        • Development, delivery and expectations of drug utilization management programs
        • Scope of appeals considerations, or procedures in place for how an appeals process works.
        • URAC educational support and training to assist with adherence to standards
      • Applying for Accreditation

        + Details

        Question: Who can apply for URAC’s Pharmacy Quality Management® accreditation program?

        Response: Health plans offering these services or standalone pharmacy organizations may apply.

        Question: How can organizations apply for Pharmacy Quality Management® accreditation?

        Response: Call URAC at (202) 216-9010.  For more information about the accreditation process, go to http://www.urac.org/healthcare/accreditation.

      • Application Submission

        + Details

        Question: How should multiple locations/sites be included in the application?

        Response: The application should list all the sites that directly support the functions of the accreditation program. If the organization's corporate headquarter is considered a site, that address must be included in the listing of sites. All sites that perform call center functions should also be included in the list of sites. Note: the locations for the onsite reviews can only be selected from the specific sites listed in the application.

      • Accreditation Benefits to Consumers

        + Details

        Question: How do URAC’s Pharmacy Quality Management® Accreditation standards benefit consumers?

        Response: The standards require organizations have policies and procedures in place that ensure:

        • Access to appropriate drugs/medications
        • Protection of health information
        • Customer service center operations and performance standards, such as timeliness and performance in answering telephone inquiries, or reasonable and accessible hours or operation.
        • Complaint and appeals tracking and resolution
        • Drug safety issues identification, resolution, and informing consumers promptly.  For instance, the standards examine policies and procedures that govern pharmacy networks and how they ensure drug safety protocols at the pharmacy level—issues such as drug interactions, whether a drug is appropriate for the consumer’s age and gender, or whether there are drug alerts that apply.
        • Accessibility and reliability of information intended for consumers, such as availability of provider directories or information about formularies and benefit coverage.
        • Methods to measure customer satisfaction
        • Access, availability, and quality and safety criteria in the pharmacy network (including any way drugs are distributed, such as retail and specialty clinics).
      • Accreditation Benefits to Purchasers

        + Details

        Question: How do URAC’s Pharmacy Quality Management ® Accreditation standards help purchasers?

        Response: Since purchasers seek PBM services on behalf of consumers, many of the same benefits apply.  In addition to those listed above, the standards require organizations have policies and procedures in place that ensure:

        • Data integrity security, so purchasers know health and personal information about the employees is safe.
        • Disclosure and verification of contractual policies, such as how payment policies with drug manufacturers were developed;
        • Disclosure of what audit rights clients have to ensure pricing methodologies remain transparent.
        • Integrity of the formulary development process.  These include standards surrounding the way drugs are selected for inclusion in formularies, such as the qualifications of those making decisions and that considerations about safety and effectiveness come before cost.
        • Operational requirements and performance standards, such as licensure and certification of staff.
      • Areas of Interest for Regulators

        + Details

        Question: In what ways will Pharmacy Quality Management® accreditation address areas of interest for regulators?

        Response: The standards require organizations have policies and procedures in place such as:

        • Conflict of interest requirements—for staff, committees, or others connected to the organization.  For example, members of a pharmacy and therapeutics or formulary committee cannot have relationships with a drug manufacturer with a product under consideration.  
        • Safeguards to ensure that financial incentives do not create conflicts of interest.
        • Access to drugs and services needed by consumers.
        • Regulatory compliance such as licensure of staff and facilities.
      • Accreditation Contract Agreement

        + Details

        Question: How do URAC’s Pharmacy Quality Management® accreditation standards address clarity in contracting agreements?

        Response: The standards require organizations have policies and procedures in place for the purchaser that ensure:

        • Disclosure of rebate structure
        • Disclosure and definition of pricing structure
        • Audit arrangements
        • Formulary decision making
      • Clinical Rigor

        + Details

        Question: How do URAC’s accreditation standards assure clinical rigor in its Pharmacy Quality Management® programs?

        Response: The standards require organizations have policies and procedures in place that ensure:

        • Clinical decisions and information are developed and delivered with the involvement and oversight of appropriate clinicians to promote optimal and cost effective drug use.
        • Clinical decisions and information are developed through an evidence-based process.
        • Clinical information undergoes timely review and updates.
        • The Pharmacy and Therapeutics Committee and formulary development and management process is based on efficacy, safety, and therapeutic need.
      • Organizations’ Content Information Level

        + Details

        Question: Are organizations required to have the content of information at a specific grade-level?

        Response: URAC will not specify that consumer content be developed for a sixth-grade (or any) reading level.  However, URAC will ask the organization to state what reading level it targets, the criteria it uses to test content against that reading level, and how it ensures that consumer content meets those criteria. Refer to the Health Literacy Communication Requirements and Consumer Education sections for additional information.
      • Regulatory Compliance

        + Details

        Question: Is an organization required to meet state and federal laws if it is not noted in the standards and/or interpretive information/commentary section?

        Response: State and federal laws supersede URAC Standards if the laws or regulations are more rigorous than URAC Standards. Conversely, an applicant must comply with URAC Standards if the standards are more stringent. If an applicant is required by law to carry out its business in a manner not consistent with URAC Standards, then the applicant may request a variance from a URAC Standard. A copy of the relevant statute or regulation must accompany the request submitted for that standard in the application.

      Accreditation Onsite Process

      • What is the look back period for selecting files for initial applicants?

        + Details
        An initial applicant is defined as an organization that has never received a URAC accreditation for the module If an applicant is applying for initial accreditation they must be prepared to provide a log of all cases, or files such as credentialing, complaints, employee records processed since the date of application submission If the Desk top Review findings identify non-compliance with the standards it is expected that the files will demonstrate changes effective from the accepted standard evidence. URAC will verify changes made have been implemented and applied to cases processed. Case files are not pre-selected before the onsite.
      • What is the look back period for selecting reaccreditation files?

        + Details
        A re-accredited organization is an organization that has been previously accredited and is applying to renew the previous accreditation If an applicant is applying for re-accreditation they must be prepared to provide a log of all cases processed since the date of the applicant's last onsite visit. Case Files are not pre-selected before the onsite.
      • How many cases will be reviewed during the onsite?

        + Details
        A minimum of thirty cases for example; case management, health call center call records, credentialing files, medical necessity standard appeals, and medical necessity expedited appeals, wellness consumer records, or disease management consumer records will be reviewed. If an area of non compliance is identified additional cases may be selected for review. The total number of cases reviewed is at the discretion of the reviewer. The size of the organization will factor into the number of cases reviewed.
      • Do case records need to be printed for the file audit?

        + Details
        No, cases may be reviewed on line if the applicant provides a super- user to navigate in the applicant's system. However, the organization must be able to print out a file if requested. Credentialing files and Provider contracts must be viewed in paper format. Contracts must be fully executed with signatures and dates.
      • Personnel/Consultants Orientation and Credentials Verification:

        + Details
        The reviewer will request a listing of personnel /consultants who function under the scope of the accreditation. For example if the organization is applying for accreditation under the Utilization Management module, the reviewer will request personnel files for those staff members who perform Utilization Management functions. A minimum 10% or 10 of the organization's personnel files will be reviewed, whichever is greater. The reviewer will look for evidence of: • Job description and resume or job application please see (Core 25) • Licensure, this will require Primary source verification of licensure (See Core 30) • Certification, if the staff member's job description requires certification the reviewer will look for evidence of primary source verification of certification. (See Core 30) • Documentation of Initial orientation (See Core 27) • Training in the current version of URAC standards as applicable to job functions (See Core 27) • Conflict of interest training (See Core 27) • Confidentiality training (See Core 27) • Signed Confidentiality Statements/Agreements • Documentation of additional training for all staff (See Core 27) • Ongoing training for all staff at a minimum annually to maintain professional competency. (See Core 27) • If the selected individual is a consultant please provide a copy of the contract • Temporary staff are subject all of the documentation above Training records may be viewed electronically.
      • Does the senior clinical staff person have to be present during the onsite?

        + Details
        Yes, the senior clinical staff person must be present during the onsite. If he/she is unable to be present please discuss the circumstances with the accreditation reviewer prior to the scheduled onsite.
      • When should an applicant expect to receive the agenda for the onsite?

        + Details
        The link for the onsite agenda will be found in the email identifying the onsite date. It is approximately half way down the email. It includes tips for a successful review, a list of documents to have available and the agenda identifying the onsite details. Onsite dates will be discussed with the contact person during the initial call with the assigned accreditation reviewer after submission of the application. URAC does not schedule onsites on federal holidays. An onsite day commences no later than 9am and concludes by 5pm. When will an onsite be cancelled? In the event of a declared emergency such as a hurricane, tornado, or terrorist act in the applicant's State. The onsite will be re-scheduled at a mutually agreeable timeframe.
      • Does the business continuity testing have to occur prior to the onsite?

        + Details
        The business continuity testing must be completed before the date of the onsite. Testing that has occurred within the last two years will meet the standard requirement. Documentation related to the testing must be provided during the onsite. The documentation should depict any identified gaps and remediation planning.
      • How do accreditation reviewers decide who to interview during the onsite?

        + Details
        The onsite agenda will list the department representatives that will be interviewed. The applicant will identify who from the following departments will be interviewed: Marketing, Regulatory Compliance, IT Privacy and Security Officers, Quality Management, and Supervisory Staff. The Senior Clinical Staff person will be interviewed. The Accreditation reviewer will randomly select non-clinical and front line clinical staff to interview.

Interested in accreditation?
Contact businessdevelopment@urac.org

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