Concurrent Review
URAC UM 19 -- v. 5.1 Proposed Revision -- Concurrent Review Timeframes
Submitted by Tom Goddard on Thu, 2008-05-15 17:57.As I noted in an earlier post, the current HUM 19, prescribing timeframes for concurrent review, fails to address situations where the patient or provider request an extension of a previously approved course of treatment in cases not involving urgent care. URAC's proposed revisions to the HUM standards fail to propose any substantive change in this standard. This is an easy fix, it seems to me, so I just now sent URAC this comment at its web page for submission of public comments on these standards:
URAC proposes no changes to the standard language of HUM 19. I respectfully suggest that this is an appropriate time to address a gap in this standard.
It currently reads as follows:
For concurrent review, the organization adheres to the following time frames: (Primary)
(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 (Primary)
(b) For requests to extend a current course of treatment, the organization issues the determination within: (Primary)
(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 (Primary)
(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. (Primary)
The gap in this standard is this: it does not address requests for extension of a current course of treatment in non-urgent cases.
Subsection (a) addresses all reductions and terminations in a previously approved course of treatment, without regard to whether it is a case involving urgent care. On the other hand, Subsection (b), which deals with patient/provider requests to extend a current course of treatment, addresses only cases involving urgent care.
What happens, then, where a patient/provider requests an extension in a case that does not involve urgent care? On this subject, the standard is silent. And yet, it is not inconceivable that such a request could be made in a non-urgent situation, as in situations like physical therapy.
I recommend that the standard be amended to read as follows:
HUM 19
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 (4)
(b) For requests to extend a current course of treatment, the organization issues the determination within: (4)
(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 not 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 (--)
(iii) 72 hours of the request for a utilization management determination, if the request for extension was received less than 24 hours before the expiration of the currently certified period or treatments. (--)
From my conversations with experienced reviewers, I believe this is, in fact, the way reviewers are addressing this issue already, and therefore would not involve a change in policy.
I do hope that the URAC Standards opportunity takes advantage of this opportunity to make an easy fix to a slightly broken standard.