Non-Certification

The original, v. 5.0 version of this standard reads as follows:

Upon request from the patient, attending physician, or other ordering provider or facility rendering service, the organization provides specific clinical review criteria upon which the non-certification was based. (Primary)

URAC, in v. 5.1, substitutes "clinical rationale" for "clinical review criteria", so that the standard now reads:

Upon request from the patient, attending physician, or other ordering provider or facility rendering service, the organization provides specific clinical rationale upon which the non-certification was based. (Primary)

It would help, it seems to me, to lay out the URAC definitions of these terms: 

• Clinical Rationale
  • A statement that provides additional clarification of the clinical basis for a non-certification determination. The clinical rationale should relate the non-certification determination to the patient’s condition or treatment plan, and should supply a sufficient basis for a decision to pursue an appeal.
• Clinical Review Criteria
  • The written screens, decision rules, medical protocols, or guidelines used by the organization as an element in the evaluation of medical necessity and appropriateness of requested admissions, procedures, and services under the auspices of the applicable health benefits plan.

This is a significant change, at least on its face.  The two terms describe distinctly different concepts, and it would appear that v. 5.1 gives the applicant more leeway than v. 5.0.  However, we've noticed that at least some URAC reviewers have been interpreting this standard more liberally than the narrow term "Clinical Review Criteria" would suggest, so it may be simply that URAC is bringing the standard into alignment with what has been the practice of the reviewers.  

Being a URAC reviewer myself for many years, I applaud such recognition of the wisdom of reviewers!