The Basics

The standard requires that your organization establish criteria for the selection of its independent reviewers.  In addition, it requires a credentials verification program for all such reviewers, as well as re-verification no less frequently than every three years.  The minimum requirements for the credentialing program are:

• verifying current licensure, current board certification, disciplinary and sanctions history, and professional experience; and
• actual or potential conflicts of interest.

Certainly, your organization may have more rigorous requirements than these minimums established by URAC; check the applicable P&P to make sure you are up-to-date on all the criteria.  

Management Tips

It is important to URAC that your credentialing system be strong enough to assure that a reviewer has current licensure and certification and no conflict of interest every time he/she receives a case file from you.  There are several suggested mechanisms you should consider including in your P&P:

• require your peer reviewers to notify you immediately if there are any changes to licenses or certifications;
• direct research of state licensing boards, NPDP, and OIG to find sanctions or disciplinary actions;
• an attestation by the peer reviewer for each case.

URAC Accreditation Tips

All of the individual elements of the standard are mandatory.

For the desktop review, you should submit a combination of the policy and procedure(s), a screenshot of your online credentialing database, if you use one, and any templates or forms that you might use, such as a conflict of interest questionnaire or attestation for the reviewer.

The on-site review will involve an examination of at least 30 randomly selected reviewer credentialing files.  100% of these files only to be in good order to pass the standard.  In addition, the members of your staff who verify credentials will be interviewed by the reviewer.  Finally, it is entirely possible that the reviewer will call at least two members of your reviewer panel.  You will be able to set up those reviews in advance.

The Basics

This standard provides specific guidelines to ensure that the individual reviewer or reviewers handling a file do not have an individual conflict of interest that would disqualify the reviewer from handling the file.  The reviewer must not have a conflict of interest (professional, family, or monetary) in connection with:

• the entity referred the file;
• the health plan;
• the consumer;
• any healthcare provider that has been (or might yet be) involved in the case, including facilities; or
• the manufacturer or developer of any therapy, procedure, device, or medication being considered for the consumer.

In addition, the standard prohibits the reviewer from accepting compensation from anyone for his/her activities in connection with the Independent review that relates to the specific outcome of the case.  Finally, the standard prohibits a reviewer from having any previous involvement with the case under review.

Note that it is individual conflict of interest that is affected here, to be contrasted with the organizational conflict of interest described in the previous two standards.  

Your organization's policy and procedures will decide whether this can be met via an attestation signed by the reviewer or some other procedure.  Be sure you know which of the various possible methods your organization uses.

Management Tips

Your organization should have a specific policy and procedure dealing with individual conflicts of interest that complies with the standard.  URAC allows you some flexibility as to how you address this, but the most common approach involves an attestation signed by the reviewers that specifically addresses each of the points of the standard.  Therefore, in addition to the policy and procedure, you probably should develop a standardized conflict of interest template, being sure to address every single component of the standard.  In addition, make sure that both your reviewers and employees handling the review files are trained in whatever mechanism you choose.

URAC Accreditation Tips

Every element of the standard carries a weight of 4.

For the desktop review, be sure to submit the policy and procedure as well as any attestation forms or other tools documenting whether the reviewer has a conflict of interest with the particular case.  In addition, submit written documentation of training of your reviewers in your policy and procedure.

The on-site review will involve not only an examination of your written documentation regarding conflict of interest, but also an interview of employees who handle case files to make sure they understand how to implement this phase of the file process.  In addition, and perhaps more importantly, the reviewer will look for documentation in each case file that he/she pulls that this important step in the file review process has been taken in every case.

The Basics

This standard requires that, if you discover that your organization has a conflict of interest in the initial review described in the previous standard, your organization must return the case to the client/referring entity.  The only exception to this rule is if, after you fully disclose the existence of that conflict of interest to the consumer, health plan, and referring entity, all of those parties execute a written consent for your organization to go ahead and conduct the independent review.

How might this happen?  When would any of these parties consent to having an independent review conducted by an organization with a conflict of interest?  This could happen if your organization has unique or highly unusual expertise that would be difficult or impossible to find elsewhere, or if time for a decision is very short, or if the conflict of interest is so minor as to be harmless.

Your organization no doubt has a policy and procedure that addresses the notification of the affected parties of the existence of a conflict and the mechanism for obtaining written consent.  Make sure you are familiar with that P&P.

Management Tips

Again, the key will be to have a robust policy and procedure that addresses the mechanism by which you would obtain written consent from all of the affected parties after full disclosure of the existence of an organizational conflict of interest.  In addition, your filing mechanisms will need be able to keep track of that documentation, whether electronic or in paper form.  We strongly recommend that you have not only a template letter by which you notify the affected parties of the existence of a conflict of interest, but also a template consent form that you provide to the affected parties for them to execute.  Finally, it will be essential that your policy and procedure clearly states that no independent review will be performed by your organization until all of the parties have executed a written consent, where an organizational conflict of interest exists.

URAC Accreditation Tips

This is a mandatory standard.

The documentary submission for the desktop review should include not only your applicable policy and procedure, but also template letters and consent forms used to implement the policy and procedure.

The on-site review will involve a review of your policies and procedures regarding conflict of interest, as well as interviews of employees who are charged with implementing that policy and procedure.  Additionally, and perhaps more importantly, the reviewer will examine a significant sample of case files to make sure that your conflict of interest policies are fully executed in your day-to-day operations.

The Basics

An excellent starting point for this module is to know how URAC defines "Independent Review":

A process, independent of all affected parties, to determine if a health care service is medically necessary and medically appropriate, experimental/investigational or to address administrative/legal issues.  Independent review typically (but not always) occurs after all appeal mechanisms available within the health benefits plan have been exhausted.  Independent review can be voluntary or mandated by law.

This standard requires that your organization, upon receiving a case for independent review, conducts an initial review of the case.  That review should address four questions:

1. Does an organizational conflict of interest exist?
2. What kind of case is this, medical necessity, experimental/investigational, administrative, or some combination of these three?
3. What is the specific issue that they're referring entity wants us to resolve?
4. Can we handle this case as a standard review, or must we expedite it?

Naturally, in order to address the first question, we need to know what a "conflict of interest" is:

• Any relationship or affiliation on the part of the organization or a reviewer that could compromise the independence or objectivity of the independent review process.  Conflict of interest includes, but is not limited to:
  • An ownership interest of greater than 5% between any affected parties;
  • A material professional or business relationship;
  • A direct or indirect financial incentive for a particular determination;
  • Incentives to promote the use of a certain product or service; 
  • A known familial relationship;
  • Any prior involvement in the specific case under review.

In order to get credit for complying with the standard, your organization no doubt has a policy and procedure that defines conflict of interest.  Be sure you know how to find a policy and procedure and what it says.  Particularly important will be for you to know who makes the determination on initial review as to whether the organization has a conflict of interest, and how he/she makes that determination.

Again, your organization no doubt has a policy and procedure that outlines the criteria upon which the second question (medical necessity versus investigational versus administrative) is decided, and who decides it.  Be familiar with that policy, and particularly how the person or persons making that decision can seek advice on difficult issues.

For the third issue, very often the referring entity will communicate what the issue is that it wants you to resolve.  If the referring entity does not do that, however, your organization should have a procedure that you should know that will determine who within your organization will make that determination and how he/she will make it.

Again, the standard-versus-expedited decision often comes from the referring entity or client.  If it does not, however, your organization should clearly identify in a policy and procedure who within your organization makes that decision and how he/she thinks it.  Be sure you're familiar with that.

Management Tips

There is a lot of pressure on the policies and procedures governing initial review.  They must be clear and completely define the "who, how, and when) of the initial review in all four components of that review.  Particularly important, too, will be the documentation of all of these actions.  As a part of or attachment to your policies and procedures, provide mechanisms to capture the decision-making process on all four issues, whether that involves paper documentation or electronic documentation.

URAC Accreditation Tips

The element requiring a review of conflict of interest is mandatory; all other elements have a weight of 3.

The documentation for the desktop review should include your detailed policies and procedures regarding initial screening on all four elements of this standard.  In addition, any forms you used to document compliance with the four elements of the standard should be submitted, as well.  This would include screenshots of any automated mechanisms for documenting the initial review.

The on-site reviewer will examine your policies and procedures and documentation (electronic or paper) of implementation of the initial review process.  In addition, he/she will interview your staff members charged with initial review and even observe them as they conduct such review to make sure that they are complying with the standard and documenting the review properly.  Finally, this is one of the many issues that will be assessed during the case file audits, so make sure that the files you provide to the reviewer for those audits include documentation of the initial review.

The Basics

This CMS standard provides:

The MAO’s written contracts with any entity that performs deemable activities that are delegated under its contract with CMS, must contain provisions that specify that the entity adhere to the delegation requirements in the MA regulation.  

This standard is fully implemented by the standards dealing with delegation agreements.  

URAC Accreditation Tips

The only documentation needed at the desktop stage is a sample a delegation agreement.

The on-site interview of personnel in charge of delegation oversight will ask:

• "What are the general terms of the delegate agreement? 
• How do you monitor compliance with CMS regulations?"

This standard provides:

The MAO’s written contracts with first tier and downstream entities must contain the provisions that contracting providers agree to safeguard beneficiary privacy and confidentiality, consistent with all Federal and State laws, and ensure accuracy of beneficiary medical, health, and enrollment information and records. 

The standard is fully implemented by P-NM 10:

The Basics

This standard was written to deal with the situation that might otherwise be considered delegation, as in the case where your organization contracts with a provider group that, in turn, contracts with an individual provider.  Rather than subject that relationship to all of the requirements of delegation oversight, the standard simply says that your basic agreement with the provider organization must contain a clause that stipulates that, if the organization should enter into a subcontract with another provider for participation in your provider networks, the relationship between the provider organization and that provider be subject to the terms of the contract between your organization and the provider organization.

Management Tips

This standard is likely to require special attention, as it is relatively new.  Your contracts likely do not have this clause unless they were written within the last three years.  So, make sure your current contracting policy and procedure contains this requirement.  In addition, make sure that it is included in your provider manual (and you'll see why this is important on the next page).  Finally, make sure that your current contract templates contain this clause.

URAC Accreditation Tips

This standard is mandatory.

See P-NM 7 for a description of the desktop and on-site review requirements.

The Basics

This standard provides:

An MAO may not prohibit a health care professional from advising or advocating on behalf of a patient.

In addition to the URAC standards prohibiting so-called "gag-clauses" in provider agreements, URAC supports this CMS standard with two standards, MAP-NM 5 and MAP-NM 6.  Those standards require that your organization:quotes in

• ensure that participating providers in your network provide information to their patients who are your members in a culturally competent manner; and
• provide consumers with disabilities with effective communications throughout the healthcare system.

The on-site document review will focus on making sure that the contracts with providersdo not contain gag clauses or improper definitions of utilization management.  In addition, provider complaints would be examined to see if there are any problems associated with requirements of the standards.

In addition, your organization is not required to cover, furnish, or pay for a particular counseling or referral service if your organization objects to the provision of that service on religious or moral grounds and provides consumers information, before and during enrollment, about any such constraints on the organization's coverage.  It is important, however, that your organization provides consumers with notification of the adoption of the policy within 90 days.

URAC Accreditation Tips

Documentation for the desktop review includes applicable policies procedures, provider manual, or sample provider or member newsletters.

The on-site interview will be directed at the medical director and provider relations and utilization management apartment staff, and will focus on the following questions:

• How do providers know who to contact when medically necessary care is not available within the plan? 
• What expectation does the plan have for oncologists in informing patients about their treatment options?

This CMS standard provides:

The MAO must establish a formal mechanism to consult with the physicians and subcontracted groups that have agreed to provide services regarding the organization’s medical policy, quality improvement programs, and medical management procedures.

URAC supports this standard through a combination of network management standards, reviewed elsewhere in this training, requiring a formal strategy to involve participating providers on clinical and payment related committees.  In addition, URAC's delegation standards and HUM standards encouraging communication with participating providers provide all the necessary support.  You have already received training in those that apply to your role in the organization.

The CMS standard provides:

The MAO must have written policies and procedures and a process for rules of physician participation and adverse participation decisions.

The Basics

URAC supports this standard with the provider dispute resolution standards addressed elsewhere.  The primary change to those standards for the purposes of Medicare Advantage is the requirement that a majority of the members of the appellate review panels be peers of the disputing provider (MAP-NM 1).  In addition, the organization and the contracting provider must provide written notice to each other before terminating the provider agreement without cause (MAP-NM 2).  

URAC Accreditation Tips

Documents you should submit for desktop review include applicable policies and procedures, credentialing committee minutes, provider manual, and a sample template termination or suspension notice to a provider.  In addition, be prepared to submit a list of terminated or suspended providers at this stage.

The on-site review interview will be directed at the medical Director and the members of the staff of the credentialing and provider relations departments.  Questions will include:

• What are the conditions of participation? 
• Is this in the contract language and or provider contract?
• When changes are made how and when are providers notified 
• What are some of the reasons that determine termination, suspension from the network?
• How are these instances investigates and does the credentialing committee make the determination?
• When providers are terminated or suspended from the network what is the process for investigation, notification, and appeal rights?
• Please provide example of quality of care reviews that resulted in termination and suspension. 
• Please show me the cases and documented letters.
• What are reportable event to the medical board?

This CMS standard provides:

The MAO implements procedures to ensure that members are not discriminated against in the delivery of health care services consistent with the benefits covered in their policy based on race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment. 

The URAC standard supporting this standard is MAP-AD 1.

The Basics

The standard sets forth a long list of factors that your organization may not use to deny, limit, or condition coverage or benefits:

• Mental or physical disability or condition;
• Claims experience;
• Receipt of health care;
• Medical history;
• Genetic information;
• Evidence of insurability, including conditions arising out of acts of  domestic violence;
• Disability;
• Race;
• Ethnicity;
• National origin;
• Religion;
• Sex;
• Age;
• Sexual orientation; or
• Source of payment.

Make sure you can find the organizational document(s) that explicitly implement this standard.

Management Tips

A general anti-discrimination clause will not suffice.  You need to be as specific, both in your P&Ps and in your staff training, as is the standard.

URAC Accreditation Tips

The desktop review submissions should include very specific applicable policies and procedures and/or applicable sections from the provider manual.  In addition, agendas and attendance sheets from staff orientation and training classes on this topic of anti-discrimination should be submitted.  Any other organizational documents that address anti-discrimination would be useful, too.

The on-site review interview will be targeted at the member services and provider relations staff members.  Three main questions that are likely to be asked are:

• How is antidiscrimination addressed in provider contracting?
• Did you receive any training pertaining to discrimination?
• How are members informed of their rights?