HUM

So what are the mandatory standards?

URAC has always had mandatory standards. However, only with version 1.0 of the Core standards developed in the early part of this decade did the current notion of “mandatory standard” emerge. Mandatory standards typically, but do not always, have to do with consumer protection. A mandatory standard is any standard that has a weight of “5”.

In order to be fully accredited, an applicant must score at least 2 out of a possible 4 points on every mandatory standard. You can only get a score of two if you pass all of the “primary” elements of a standard. Therefore, what really is mandatory is that an applicant pass all of the primary elements of all of the mandatory standards.

The mandatory standards for the Health Utilization Management (v. 5.1) module are:

HUM - 9 - Pre-Review Screening Non-Certifications
HUM - 10 - Initial Clinical Reviewer Qualifications
HUM - 12 - Initial Clinical Reviewer Non-Certifications
HUM - 13 - Peer Clinical Review Cases
HUM - 14 - Peer Clinical Reviewer Qualifications
HUM - 22 - Written Notice of Non-Certification Decisions and Rationale
HUM - 30 - Non-Certification Appeals Process
HUM - 31 - Appeals Process
HUM - 32 - Appeal Peer Reviewer Qualifications
HUM - 33 - Expedited Appeals Process Timeframe

Naturally, an applicant for HUM also will have to meet all the mandatory standards for Core, v. 2.1, posted here. 

UM 1 provides:

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).

The standard is weighted "4", and all subsections are primary elements.

A standard covers both internally-developed clinical criteria and commercial criteria.  However, the key distinction is in the review and approval process described in subsections (c) and (d).  For internally developed clinical criteria, the process is quite clear: the organization and actively-practicing physicians must review the criteria which, in turn, also must be approved by the medical director or clinical director.

For commercial criteria, the standard is a bit different in application, if not in general requirement.  Most commercial vendors of criteria update those criteria annually.  This annual updating process generally takes care of the requirements of subsection (c).   Of course, the criteria still need to be approved by the medical director.  However, if the organization does not receive annual updates from the commercial vendor, it is still incumbent upon the organization to put the criteria through the annual review required by subsection (c), including a review by actively practicing physicians.

The documentation required to be submitted for desktop review is straightforward: a policy and procedure describing the development and approval of criteria along with sample pre-review scripts or clinical criteria.

The real test, however, will be during the on-site review.  It is during that stage of the accreditation process that the reviewer will be asking to see specific documentation of the review process for the criteria.  The Program Guide outlines the process:

·         Documentation indicating medical director or clinical director development and approval of clinical review criteria or scripts

·         Documentation indicating annual evaluation of clinical review criteria and scripts

·         Clinical case records illustrating initiation of the review process, pre-review screening, and initial clinical review, concurrent review and retrospective review.

What will be important for companies undergoing the reaccreditation process to remember is that the documentation of the clinical criteria review process must show annual review and approval.  It will not suffice for a three-year accredited company to show merely that it looked at the criteria recently.  Rather, documentation only to demonstrate the annual review required by this standard.