The Basics

Standard requires that your organization conducts an employment background check for employees who handle pharmaceuticals and patient data.  That background check must be both a criminal background check and involve drug testing and/or screening.

The criminal background check must include a minimum identification check, criminal history, a record as a sex offender, and other relevant information.  The drug testing and screening that is contemplated by the standard should not be limited to illegal drugs.  This is a consumer safety issue, so any substance abuse issue that could affect consumer safety, including alcohol abuse, is within the scope of the standard.

Management Tips

Your policies and procedures should not only address the two elements of this standard, i.e., background check and drug check, which also include mechanisms for taking corrective action in case the organization's substance abuse policy is violated.  The policies and procedures also should include a discussion as to how your employees will be trained regarding your screening programs.  Finally, your program should have a mechanism of recording consumer complaints regarding violations of access to personal information of the consumer.

URAC Accreditation Tips

Both of the elements of the standard are mandatory.

For the desktop review, submit your conference of policies and procedures regarding background checks, substance abuse, and training.

During on-site review, the reviewer will examine a log of consumer complaints in search of evidence that you handle complaints about personal information violations appropriately.  Be prepared to produce evidence that, where such a complaint has been lodged, your organization has taken appropriate corrective action.

The Basics

This standard addresses a situation where a consumer needs a drug that would otherwise be excluded by his or her benefit plan, but still should get the medication.  It addresses situations like natural disaster, lost supplies, prescriptions needed before a long journey, or damaged medications.  The standard requires that your organization have a clear policy and procedure that allows for such exceptions and describes precisely how they are to be handled so that the consumer is not without needed medication.

Management Tips

Writing a policy and procedure to cover this requirement is the easy part.  The more challenging part is to make sure that the appropriate customer service and other staff members are adequately trained on how to handle these unusual circumstances.  Therefore, work closely with your training department to make sure that your policies and procedures are fully implemented.  It is also important to remember that while most of the situations that arise under this standard will be on a case-by-case basis, in some instances, notably natural disaster, you may be dealing with many affected consumers at one time.  Make sure your policies and procedures are sufficiently robust to address such a situation.

URAC Accreditation Tips

This is a mandatory standard.

The initial documentary submissions should include your policies and procedures for refills, as well as any script that you have developed for customer service Representatives to implement those policies.  In addition, if you have regulations at the federal or state level that address these issues, be sure to include them in your submission.

The reviewer will interview of customer service staff and the compliance officer to assess understanding of how your organization complies with the standard.  In addition, the reviewer's examination of your complaint log may also lead to an inquiry about the implementation of the standard in the event that complaints reveal that you have not fully implemented your policies and procedures.

The Basics

This straightforward standard simply requires that your organization's electronic claims processing mechanism complies with the standards of the National Council for Prescription Drug Program.  The standard transactions are the codes set standards under federal privacy law for organizations operating in the retail pharmacy world.

Management Tips

While your organization no doubt complies with the standards, it will be particularly important that you clearly document, through policies and procedures for claims processing, that this is an internal requirement of your organization.  In addition, you will need to make sure that your pharmacy provider manual and your pharmacy agreements are consistent with your policies and procedures on claims processing.

URAC Accreditation Tips

This is a mandatory standard.

For the desktop review, you will need to submit your policies and procedures, pharmacy provider manual, and agreement template.

The reviewer will interview your information technology leadership and regulatory compliance officer about your claims processing standards.  In addition, the reviewer will want to see documentation that you monitor compliance with these standards.

The Basics

This very important standard requires that your organization have a process by which it may protect consumers from a participating pharmacy that poses a health risk to consumers or promotes fraud and abuse.  The process must provide for an expedited investigation and access by the suspended pharmacy, after the suspension, to the dispute resolution mechanism described in the previous page.  This standard is particularly important because it is a consumer safety mechanism, always at the top of the accreditation priority list.

Management Tips

Typically, organizations address the situation by empowering a senior clinician within the organization with a great deal of flexibility to suspend a pharmacy that poses a health or fraud risk.  URAC expects that senior clinician to have broad discretion that he or she will exercise when convinced of the health or fraud danger.  That discretion is counterbalanced by the fact that pharmacy, after suspension, will still have access to dispute resolution process.  The key here is that the senior clinician be able to do what he or she needs to do to protect consumers without getting bogged down in time-consuming dispute resolution procedures.

URAC Accreditation Tips

Most of the elements of the standard are mandatory.

The key document for the standard, of course, is the policy and procedure and/or pharmacy provider manual that describes the dispute resolution process, including the suspension mechanism required by the standard.

During the on-site review, the reviewer will ask for a list of any pharmacies that have been suspended under this mechanism.  It is very likely that you have none to report, but if you do, the reviewer will want to see the files.  In addition, if the committee is involved at any point in these processes, the reviewer will want to examine committee meeting minutes.   Finally, it will be very important that, during the interview process, the senior clinician with the authority to suspend pharmacies understands his or her responsibility to act expeditiously.

The Basics

This standard requires your organization to establish a pharmacy dispute resolution process to address situations where your organization makes a decision, that the pharmacy contests, involving its

• status within the network; or
• competency or conduct; or
• distribution channel contractual issues.

The exact mechanism is largely up to your organization to establish, so long as it stays within any external requirements that may be imposed by contract or regulation.

Management Tips

We recommend that dispute resolution be clearly spelled out in the pharmacy provider manual.  An alternative location for that description could be in policies and procedures, but the reviewer is likely to favor a document, like the provider manual, that is shared with the pharmacies.  In addition, you'll want to make sure that there is nothing in your contract with pharmacies that is inconsistent with the dispute resolution mechanism description.  Make sure that whatever mechanism you come up with is fair on its face.  Giving a participating pharmacy industry record resolution mechanism that seems to have a predetermined outcome will not pass muster.

URAC Accreditation Tips

Each of the three elements of the standard carries the weight of 4.

Your initial documentary submission should include the pharmacy provider manual or other policy and procedure that describes the dispute resolution process, as well as any written agreements that refer to the process.  In addition, if you handle pharmacy disputes through a committee mechanism, documentation about the committee's involvement in the process should be submitted, as well.

During the on-site review, the reviewer will ask for a list of complaints or grievances made by participating pharmacies, as well as a list of pharmacy disputes.  From those lists, the reviewer will select a sample of pharmacy dispute files and examine them more closely to make sure that you are complying with your own policies and procedures.  In addition, your network management staff will need to know how the dispute resolution process works.

The Basics

One of the reasons we have emphasized in the previous couple of pages the importance of having required contract language embodied in the pharmacy provider manual and/or policies and procedures is because of the existence of this standard.  Because it is not expected that you will go out and recontract with all of the participating pharmacies in your network with which you have agreements that do not comply with these accreditation standards, you may make up for the non-compliance of these older contracts by having the required terms in these administrative documents.  The reason we recommend having the required language incorporated into your pharmacy provider manual is that this is a document that you share with your pharmacies, whereas you may not share all of your policies and procedures with pharmacies.

Management Tips

Naturally, this standard is not applicable in the event that all of your pharmacy agreements comply with the previous couple of standards.  However, because there is a possibility that, somewhere out there, you have a letter of agreement or an old contract that does not comply with the requirements of these standards, it is a best practice to make sure that your provider manual contains all of the required language for your pharmacy contracts.

URAC Accreditation Tips

Each element of the standard is weighted 4.

Documentation for this standard is straightforward, in that you need only submit the pharmacy provider manual and/or policies and procedures that "fill in the gaps" of your provider agreements.

In addition to the review of contracts described previously, the on-site review will involve an interview with network management staff and leadership as well as an examination of any tracking mechanisms you have for pharmacy agreements. 

The Basics

This standard deals with the situation in which your organization contracts with an intermediary organization that then, in turn, contracts with the participating pharmacy.  The standard requires that your contract with the intermediary makes it clear that the intermediary must bind the participating pharmacies with which it contracts to the terms of your agreement with the intermediary.  The purpose of the standard is to make sure that the fact that there is an organization between your organization and the participating pharmacy does not let the participating pharmacy off the hook for compliance with the previous standard's requirements for a participating pharmacy agreement.

Management Tips

In addition to making sure that your pharmacy intermediary agreements contain the subcontracting clause required by this standard, binding downstream pharmacies to the terms of the intermediary agreement, it will be imperative that your pharmacy provider manual and/or applicable policies and procedures also address this issue.  Beyond that, it would be advisable to make sure your policies and procedures and/or manual establish a mechanism for tracking these relationships, as they are of particular concern to reviewers.

URAC Accreditation Tips

This is a mandatory standard.

The initial documentation is simple: submit your contracting policy and procedure and a template agreement containing the required language.

The on-site review will involve an examination of your contracts with pharmacy intermediaries, as well as an interview with network management staff to make sure that they understand this important requirement.

The Basics

Your organization's pharmacy contracts must contain certain provisions listed in this standard:

• list of the parties to the contract
• preconditions for the mission as a participating pharmacy (for example, licensure)
• the mutual obligations of the parties to the agreement
• events that would entitle your organization to modify or end the participation privileges of a participating pharmacy
• the term of the agreement and any procedures for terminating the agreement
• rules surrounding pharmacy audits
• any rules regarding at your organization's access to applicable consumer records
• a listing of services to be provided in any restrictions on the services
• claims submission requirements and limits on consumer billing
• fees and payment methodology
• dispute resolution
• a protection of the confidentiality of personal health information of consumers

Management Tips

For documentary obligations for the standard can be met in a variety of ways, but include for most organizations not only a template agreement that meets all of the requirements of the standard, but a policy and procedure or pharmacy provider manual that also addresses most if not all of the requirements of this standard.  We recommend that your pharmacy provider manual contain as many of these elements as makes sense (excluding, of course, provisions like listing of the parties).  Make sure that the policy and procedure and template contracts are in accord with each other.

URAC Accreditation Tips

Each of the elements of the standard is weighted 4.

Your contracting policy and procedure and template pharmacy agreements will be your minimum submission for desktop review.  We also recommend submitting a list of any major revisions to your contracts with in the last couple of years.

During the on-site review, your contracts will be examined for compliance with the standard.  If four or more contracts are found to have suffered from the same deficiency, the reviewer is likely to find a "pattern" of noncompliance with the element, resulting in a loss of points.

The Basics

This standard requires, very simply, that your organization have a written agreement with every participating pharmacy in its various networks.  Of course, it may be that many of the pharmacies in your network are contracting with your organization through a single contract with an entire chain of pharmacies or a pharmacy services administrative organization.  That is a perfectly appropriate arrangement.  The key is, every pharmacy has to be bound, somehow, by contract to your organization.  The chances are that your organization has a basic template agreement that many, if not most, of your pharmacies have signed.

Management Tips

This is one of those standards for which you need both a policy and procedure and evidence that you have implemented the policy and procedure, in this case, one or more template pharmacy agreements.  The policy and procedure should go beyond a mere requirement that all pharmacies have a contractual relationship with your organization, but also should include mechanisms by which you can assure that no pharmacy is listed in your pharmacy provider directory unless a contract has been executed.

URAC Accreditation Tips

This is a mandatory standard.

The initial documentary submission should be little more than your contracting policy and procedure plus any current templates for individual or chain pharmacy agreements.

The on-site review, in addition to the network-management interview, will involve an examination of selected provider contracts.  The reviewer will ask for a pharmacy provider directory, select at least 30 pharmacies from that directory, and ask you to produce a contract for each one.

The Basics

This standard requires that your organization implement a pharmacy relations program for your participating pharmacies.  It sets forth several components that are required of this pharmacy relations program:

• a communications plan that addresses new pharmacy orientation, updating network activities, notice of changes in contract provisions, advising pharmacies on how to obtain information about benefits, eligibility, formularies, and appeals, and mechanisms for obtaining participating pharmacy manuals;
• help for pharmacies and their staffs on various network issues; and
• processes for receiving suggestions from participating pharmacies on how your organization can best serve its consumers.

Management Tips

Our recommendation is that you prepare a comprehensive document that embraces all of your provider relations issues.  At the very least, we suggest that you have a clearly-identified communications plan to guide your communications with participating pharmacies.  That communications plan should address all the various means of communicating with providers, including newsletters, online medications, "blast faxes", and telephone services.  

It also will be important to be able to document how you receive feedback from participating pharmacies, whether through a formal survey mechanism or through a solicitation of less-formal suggestions.

URAC Accreditation Tips

Seven of this standard's eight elements are weighted 4, while the element about receiving suggestions and guidance from pharmacies is weighted 3.

The initial documentation submissions should include not only your governing policies and procedures and communications plan, but also a few examples of your mechanisms for communication, such as newsletters, screenshots of provider-facing webpages, etc.

In addition to the network-management interview, the on-site review will focus on an examination of any recent notices sent to pharmacies regarding changes in contract or fees, as well as a complaint log that tracks pharmacy complaints.