The Basics

The standard requires that your organization establish criteria for the selection of its independent reviewers.  In addition, it requires a credentials verification program for all such reviewers, as well as re-verification no less frequently than every three years.  The minimum requirements for the credentialing program are:

• verifying current licensure, current board certification, disciplinary and sanctions history, and professional experience; and
• actual or potential conflicts of interest.

Certainly, your organization may have more rigorous requirements than these minimums established by URAC; check the applicable P&P to make sure you are up-to-date on all the criteria.  

Management Tips

It is important to URAC that your credentialing system be strong enough to assure that a reviewer has current licensure and certification and no conflict of interest every time he/she receives a case file from you.  There are several suggested mechanisms you should consider including in your P&P:

• require your peer reviewers to notify you immediately if there are any changes to licenses or certifications;
• direct research of state licensing boards, NPDP, and OIG to find sanctions or disciplinary actions;
• an attestation by the peer reviewer for each case.

URAC Accreditation Tips

All of the individual elements of the standard are mandatory.

For the desktop review, you should submit a combination of the policy and procedure(s), a screenshot of your online credentialing database, if you use one, and any templates or forms that you might use, such as a conflict of interest questionnaire or attestation for the reviewer.

The on-site review will involve an examination of at least 30 randomly selected reviewer credentialing files.  100% of these files only to be in good order to pass the standard.  In addition, the members of your staff who verify credentials will be interviewed by the reviewer.  Finally, it is entirely possible that the reviewer will call at least two members of your reviewer panel.  You will be able to set up those reviews in advance.

The Basics

This standard provides specific guidelines to ensure that the individual reviewer or reviewers handling a file do not have an individual conflict of interest that would disqualify the reviewer from handling the file.  The reviewer must not have a conflict of interest (professional, family, or monetary) in connection with:

• the entity referred the file;
• the health plan;
• the consumer;
• any healthcare provider that has been (or might yet be) involved in the case, including facilities; or
• the manufacturer or developer of any therapy, procedure, device, or medication being considered for the consumer.

In addition, the standard prohibits the reviewer from accepting compensation from anyone for his/her activities in connection with the Independent review that relates to the specific outcome of the case.  Finally, the standard prohibits a reviewer from having any previous involvement with the case under review.

Note that it is individual conflict of interest that is affected here, to be contrasted with the organizational conflict of interest described in the previous two standards.  

Your organization's policy and procedures will decide whether this can be met via an attestation signed by the reviewer or some other procedure.  Be sure you know which of the various possible methods your organization uses.

Management Tips

Your organization should have a specific policy and procedure dealing with individual conflicts of interest that complies with the standard.  URAC allows you some flexibility as to how you address this, but the most common approach involves an attestation signed by the reviewers that specifically addresses each of the points of the standard.  Therefore, in addition to the policy and procedure, you probably should develop a standardized conflict of interest template, being sure to address every single component of the standard.  In addition, make sure that both your reviewers and employees handling the review files are trained in whatever mechanism you choose.

URAC Accreditation Tips

Every element of the standard carries a weight of 4.

For the desktop review, be sure to submit the policy and procedure as well as any attestation forms or other tools documenting whether the reviewer has a conflict of interest with the particular case.  In addition, submit written documentation of training of your reviewers in your policy and procedure.

The on-site review will involve not only an examination of your written documentation regarding conflict of interest, but also an interview of employees who handle case files to make sure they understand how to implement this phase of the file process.  In addition, and perhaps more importantly, the reviewer will look for documentation in each case file that he/she pulls that this important step in the file review process has been taken in every case.

The Basics

This standard requires that, if you discover that your organization has a conflict of interest in the initial review described in the previous standard, your organization must return the case to the client/referring entity.  The only exception to this rule is if, after you fully disclose the existence of that conflict of interest to the consumer, health plan, and referring entity, all of those parties execute a written consent for your organization to go ahead and conduct the independent review.

How might this happen?  When would any of these parties consent to having an independent review conducted by an organization with a conflict of interest?  This could happen if your organization has unique or highly unusual expertise that would be difficult or impossible to find elsewhere, or if time for a decision is very short, or if the conflict of interest is so minor as to be harmless.

Your organization no doubt has a policy and procedure that addresses the notification of the affected parties of the existence of a conflict and the mechanism for obtaining written consent.  Make sure you are familiar with that P&P.

Management Tips

Again, the key will be to have a robust policy and procedure that addresses the mechanism by which you would obtain written consent from all of the affected parties after full disclosure of the existence of an organizational conflict of interest.  In addition, your filing mechanisms will need be able to keep track of that documentation, whether electronic or in paper form.  We strongly recommend that you have not only a template letter by which you notify the affected parties of the existence of a conflict of interest, but also a template consent form that you provide to the affected parties for them to execute.  Finally, it will be essential that your policy and procedure clearly states that no independent review will be performed by your organization until all of the parties have executed a written consent, where an organizational conflict of interest exists.

URAC Accreditation Tips

This is a mandatory standard.

The documentary submission for the desktop review should include not only your applicable policy and procedure, but also template letters and consent forms used to implement the policy and procedure.

The on-site review will involve a review of your policies and procedures regarding conflict of interest, as well as interviews of employees who are charged with implementing that policy and procedure.  Additionally, and perhaps more importantly, the reviewer will examine a significant sample of case files to make sure that your conflict of interest policies are fully executed in your day-to-day operations.

The Basics

An excellent starting point for this module is to know how URAC defines "Independent Review":

A process, independent of all affected parties, to determine if a health care service is medically necessary and medically appropriate, experimental/investigational or to address administrative/legal issues.  Independent review typically (but not always) occurs after all appeal mechanisms available within the health benefits plan have been exhausted.  Independent review can be voluntary or mandated by law.

This standard requires that your organization, upon receiving a case for independent review, conducts an initial review of the case.  That review should address four questions:

1. Does an organizational conflict of interest exist?
2. What kind of case is this, medical necessity, experimental/investigational, administrative, or some combination of these three?
3. What is the specific issue that they're referring entity wants us to resolve?
4. Can we handle this case as a standard review, or must we expedite it?

Naturally, in order to address the first question, we need to know what a "conflict of interest" is:

• Any relationship or affiliation on the part of the organization or a reviewer that could compromise the independence or objectivity of the independent review process.  Conflict of interest includes, but is not limited to:
  • An ownership interest of greater than 5% between any affected parties;
  • A material professional or business relationship;
  • A direct or indirect financial incentive for a particular determination;
  • Incentives to promote the use of a certain product or service; 
  • A known familial relationship;
  • Any prior involvement in the specific case under review.

In order to get credit for complying with the standard, your organization no doubt has a policy and procedure that defines conflict of interest.  Be sure you know how to find a policy and procedure and what it says.  Particularly important will be for you to know who makes the determination on initial review as to whether the organization has a conflict of interest, and how he/she makes that determination.

Again, your organization no doubt has a policy and procedure that outlines the criteria upon which the second question (medical necessity versus investigational versus administrative) is decided, and who decides it.  Be familiar with that policy, and particularly how the person or persons making that decision can seek advice on difficult issues.

For the third issue, very often the referring entity will communicate what the issue is that it wants you to resolve.  If the referring entity does not do that, however, your organization should have a procedure that you should know that will determine who within your organization will make that determination and how he/she will make it.

Again, the standard-versus-expedited decision often comes from the referring entity or client.  If it does not, however, your organization should clearly identify in a policy and procedure who within your organization makes that decision and how he/she thinks it.  Be sure you're familiar with that.

Management Tips

There is a lot of pressure on the policies and procedures governing initial review.  They must be clear and completely define the "who, how, and when) of the initial review in all four components of that review.  Particularly important, too, will be the documentation of all of these actions.  As a part of or attachment to your policies and procedures, provide mechanisms to capture the decision-making process on all four issues, whether that involves paper documentation or electronic documentation.

URAC Accreditation Tips

The element requiring a review of conflict of interest is mandatory; all other elements have a weight of 3.

The documentation for the desktop review should include your detailed policies and procedures regarding initial screening on all four elements of this standard.  In addition, any forms you used to document compliance with the four elements of the standard should be submitted, as well.  This would include screenshots of any automated mechanisms for documenting the initial review.

The on-site reviewer will examine your policies and procedures and documentation (electronic or paper) of implementation of the initial review process.  In addition, he/she will interview your staff members charged with initial review and even observe them as they conduct such review to make sure that they are complying with the standard and documenting the review properly.  Finally, this is one of the many issues that will be assessed during the case file audits, so make sure that the files you provide to the reviewer for those audits include documentation of the initial review.

The Basics

This standard sets for the minimum requirements for your appeals records:

• Patient name
• Name of the consumer or prescriber
• Copies of all patient correspondence
• Actions taken and the dates they were taken, including decisions, correspondence, and resolution
• Minutes from any appeal proceedings
• The name and credentials of the appeals reviewer for each case
• The specific clinical review criteria upon which the non-certification was based

Management Tips

Note that this standard applies not only to the records themselves, but to the Appeals P&P.  In other words, your P&P needs to be explicit about your appeals record-keeping practices.  

URAC goves you flexibility about these records and their storage -- electronic and paper are both fine.  

URAC Accreditation Tips

All five elements of this standard are weighted 4.

The Appeals P&P and any logs containing the required information should be submitted for desktop review.

The onsite reviewer will look at your log and your case files to verify compliance with this standard.

The Basics

This standard prescribes the minimum requirements for the written notice of an adverse appeal decision (one upholding the initial denial of the request for certification):

• It must be sent to the patient and ordering provider or facility
• It must state the principal reasons for the decision
• It must state that your organization will provide the clinical rationale underlying decision in response to a written request
• It must describe any additional appeal mechanisms and how to access them, if they exist

Management Tips

See the earlier standard on the notice of denial of certification for a full discussion of the principal reason and clinical rationale issue.  The same issues that apply to that letter apply to this letter.  Make sure the case files contain the written notice and that it is dated.

URAC Accreditation Tips

The three elements of the standard are weighted 4.

Again, the appeals P&P and applicable templates are what you submit to AccreditNet.

The onsite reviewer will focus on appeals case files and staff interviews.

The Basics

This standard requires that the written notification of your standard appeal the decision be sent within 30 calendar days of your organization's receipt of the request for an appeal.  That receipt of the request for appeal is when the organization's mailroom first receives the request, not necessarily when the drug utilization management department receives it.  That notice needs to go to both the patient and the ordering provider or treating facility.

Management Tips

As with expedited appeals, the clock starts ticking when the request for appeal first hits your organization, not your department.  That means any part of your organization, including a call to the customer service department, or a letter to a mail room.  All delays in getting that request into the right hands in the DrUM department count against the time frame embodied in this standard.  Date-stamping, therefore, becomes very important.

Make sure your appeals tracking mechanism can distinguish between expedited and standard appeals.

URAC Accreditation Tips

This standard is mandatory.

Submit the appeals P&P and template appeals correspondence at the desktop review stage.

The onsite reviewer will look at your appeal tracking log, select a certain number of files, and review them to make sure you comply with the time frame required by this standard.

The Basics

This standard's purpose is to establish time frames for notification of the patient and provider in the event of expedited appeals.  There are two of them:

• 72 hours from the request to a verbal notification of the appeals decision
• 3 calendar days from the verbal notification to a written notification of the appeals decision

The 72-hour verbal notice need go only to the requesting party, whether it be the prescriber or the patient.  Only the written notification needs to go to both the consumer and the provider.  

URAC defines expedited appeal as any appeal in a case involving any situation in which applying normal time standards would threaten the life or health of the consumer or the ability of the consumer to regain maximum function or would subject the patience to severe pain that can't be adequately managed without the requested care.

Management Tips

Make sure your P&P on the topic is clear that the clock starts ticking on these time frames when the request to initiate the appeal is made.  that initiaion happens regardless of whether the request is in writing or via telephone.  Note, too, that the clock starts on written notification when the request lands in the mail room or receptionist's desk, not the UM department.

It will be particularly important that your appeal record system can capture:

• the date and time the organization received a request for appeal (date- and time-stamping will be helpful);
• the date and time of the initial notification; and
• the date and time of the written notification.

URAC Accreditation Tips

This standard is mandatory.

Again, the desktop submission is only the P&P and sample correspondence.  

The onsite review will focus on the case files of expedited appeals.

The Basics

This standard establishes to be minimum requirements for the health professionals who conduct appeals from non-certification decisions.  At a minimum, such professionals must:

• be either a licensed physician, pharmacist, or other licensed health care professional;
• be board certified (if applicable);
• be in the same or similar specialty as typically manages the medical condition, procedures, or treatment under review;
• neither be the person who made the original decision not to grant certification nor a subordinate of that person.

Your organization may have its own panel of appeals reviewers, or it may refer all such appeals to an independent review organization ("IRO").  Naturally, the standard applies only for those appeals that your organization handles for its clients.  Many clients retain the rights to handle the appeals themselves, and therefore remove your organization's need to comply with the standard for those appeals.

Management Tips

Unfortunately, this standard is more confusing than it might initially appear.  The main confusion arises out the very real possibility that the appeal reviewer is a pharmacist, as permitted by subsection (a), and yet required to be in a "similar specialty that typically manages a medical condition, procedure, or treatment," as required by element (d).  URAC has a history of giving great deference to the treating physician about the specialty of the person conducting the appellate review.  Therefore, if your organization typically has pharmacists conducting the review on appeal, you also should be fully prepared to refer to the appeal to a physician specialist, should the prescriber request that such a professional review the appeal.  An even safer approach would be to refer all appeals to a URAC-accredited IRO.

URAC Accreditation Tips

All of the elements of this standard are mandatory except for the board certification requirement, which is weighted 3.

For the desktop review, you should submit not only the applicable policy and procedure, but also job description of a health professional that conducts appeals and a sample template of correspondence related to appeals (such as the denial of certification written notification).

During the on-site review, the URAC reviewer will select 30 appeals files from your appeals law.  He/she will examine those files for evidence that appropriately qualified healthcare professionals are performing the review on appeal.  You should also be prepared to present the full list of names and specialties of appeal reviewers, along with credentialing information about the licensure and board certification of each.

The Basics

This standard adds four requirements for your organization's DrUM appeals process:

• The patient and/or provider(s) may submit additional information in their effort to overturn the original denial of certification
• Your organization must take all that information, plus all the information originally submitted, into account as it considers the appeal
• The appeal must be reviewed by a licensed health professional (physician or otherwise) who is in the sort of specialty as typically manages the medical condition, procedures, or treatment under review
• Your organization must go along with a decision by the appeal reviewer to overturn a previous denial of certification, although it does have the option to pay even if the reviewer upholds the denial

Management Tips

Make sure your P&P is clear on the point that these appeals standards refer only to appeals from denials of requests for certifications.  Administrative denials are not the subject of this or any of the UM appeals standards.

Some organizations contract with an IRO to perform the review function.  Contracting with a URAC-accredited IRO will save a substantial amount of headaches related to delegation oversight.

Read carefully the next page, about DrUM 23, for more information on the qualifications of the appeals reviewer.

URAC Accreditation Tips

All four elements of this standard are mandatory.

As in most of the other appeals standards, you'll be fine submitting only the applicable P&P and template correspondence regarding appeals rights.

The onsite review will focus on a review of case files of appeals of denials of certification.