Interpretations

URAC HUM 20 provides:

For certifications, the organization: (Primary)

(a) Has a process for notification of the attending physician or other ordering provider, facility rendering service, and patient: (Primary)

(b) Includes tracking information (such as reference number) in the notice of certification; and (Secondary)

(c) Upon request from the attending physician or other ordering provider, facility rendering service, or patient, provides written notification of any certification. (Secondary)

This standard is weighted "4".

There are few things to note about this standard. The notification referred to in subsection (a) can be verbal, electronic (email or fax), or a mailed letter. A particular curiosity is the use of the word "and" between the provider and the patient in this subsection. A literal reading of the standard would suggest that the organization must notify both. How many of us, though, ever receive direct notification from our insurers or UM companies of a certification decision? Darn few, I would suggest. The good news is that URAC has made it clear that it is acceptable to have the provider notify the patient. A word of caution -- your P&P on the subject should clearly place the obligation on the provider to let the patient know of the certification decision.

The "tracking number" in subsection (b) is a number that the consumer or the provider can use to track down the authorization, should they have to call the organization.

Documentation to be submitted to AccreditNet is straightforward -- a P&P and sample correspondence should suffice. During the onsite review, the URAC reviewer, in her examination of clinical review files, look for documentation of this notification, either in the form of certification letters or notes in the file.