URAC Accreditation

UM 26 provides:

The organization, when conducting routine prospective review, concurrent review, or retrospective review:

(a) Accepts information from any reasonably reliable source that will assist in the certification process;

(b) Collects only the information necessary to certify the admission, procedure or treatment, length of stay, or frequency or duration of services

(c) Does not routinely require hospitals, physicians, and other providers to numerically code diagnoses or procedures to be considered for certification, but may request such codes, if available;

(d) Does not routinely request copies of all medical records on all patients reviewed;

(e) Requires only the section(s) of the medical record necessary in that specific case to certify medical necessity or appropriateness of the admission or extension of stay, frequency or duration of service, or length of anticipated inability to return to work; and

(f) Administers a process to share all clinical and demographic information on individual patients among its various clinical and administrative departments that have a need to know, to avoid duplicate requests for information from enrollees or providers.

The standard is weighted “4”, and only subsections (b) and (e) are primary elements.

The standard can best be understood as providing protection for the patient and providers from abusive and/or unnecessary requests for information upon which to base a certification determination.  In a nutshell, it requires that the organization use “all reasonable sources of information to collect only the information required,” and to share that information within the organization “so as to avoid repeated requests for information from enrollees or providers.”

This is one of those policies in which it is best to take the hint in the Program Guide: “UM organizations may take language from the URAC standards and weave it into their policies and procedures, evaluating it to make sure that it reflects their current way of doing business.”

In our experience as URAC consultants, the most common required change in organization’s policies and procedures on the subject is the elimination of a routine requirement numerically coded diagnoses or procedures.    The standard is quite clear in stating that such a routine requirement is simply not allowed.