URAC HUM

The v. 5.1 upgrade to UM 34 is a partner to the revision to UM 33 (see blog on that standard here).  Like the UM 33 revision, this is billed as a "clarification of intent" standard.  Also like the UM 33 revision, it is a significant clarification.

The 5.0 version read:

Standard appeals are completed, and written notification of the appeal decision issued, within 30 calendar days of the receipt of the request for appeal. (Primary)

The question not answered by this standard was "to whom does the notification go?"  But then, one would have thought that UM 35 answered the question.  That standard reads, in relevant part:

For appeals determinations, the organization issues written notification of the adverse appeal decision to the patient and attending physician or other ordering provider or facility rendering service . . ..

But this deals only with affirmations of non-certifications -- what about the appeals that overturn the "non-certs"?  

URAC sorts it all out in the v. 5.1 UM 34:

Standard appeals are completed, and written notification of the appeal decision issued, within 30 calendar days of the receipt of the request for appeal to the patient and attending physician or other ordering provider or facility rendering service. (Primary)

In other words, the written notice of the appeal decision, no matter which way the decision goes, must be sent to both the patient and the provider.

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.

The v. 5.1 "upgrade" for UM 33 is billed as a "clarification of intent", which sounds minor.  However, for some applicants, the "clarification" could be a bigger deal than might be suggested. 

The standard's purpose is to establish a time frame for notification of the patient and provider in the event of expedited appeals.  The previous version (v. 5.0) read:

Expedited appeals are completed with verbal notification of determination within 72 hours of the request followed by a written confirmation of the notification within 3 calendar days. (Primary)

What is unclear about this is to whom each of these two notifications, verbal within 72 hours and written within 3 days, must go.  Version 5.1 clears that up:

Expedited appeals are completed with verbal notification of determination to the requesting party within 72 hours of the request followed by a written confirmation of the notification within 3 calendar days to the patient and attending physician or other ordering provider or facility rendering service.  (Primary)

So, the 72-hour verbal notice need go only to the requesting party, whether it be the provider or the patient.  Only the written notification needs to go to both the consumer and the provider.  This surely will be a relief to those URAC applicants that were playing it safe and giving verbal notice to everybody in the first 72 hours.

Playing it safe with a standard like this is not a bad strategy: you don't mess around with mandatory standards. 

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! 

This standard, while easy to comply with, is not a slam dunk.  It provides:
The organization:

(a) Requires utilization management staff to identify themselves by name, title, and organization name; and

(b) Upon request, verbally informs patients; facility personnel; the attending physician and other ordering providers; and health professionals of specific utilization management requirements and procedures.

It carries a weight of only 3, and neither of its subsections is primary.  So, it is surely true to say that you can miss this all together and still have a great shot at accreditation.  However, since it is our theory as URAC consultants that we should leave no points on the table, is worth just a little extra staff training time to sweep up these readily available points.

The most common mistake that we have found relating to this standard happens when utilization management staff members identify themselves only by name and organization, omitting the job title.  This, obviously, is both easy to detect and easy to fix.

Less common, but perhaps slightly more difficult to address is the requirement of subsection (b).  A good way to diagnose problems with the standard is periodically to pose such requests to the members of your utilization management staff.  The question might sound like this: “imagine that I am a patient, and I want to know what the procedures are to get my procedure approved, and I want you to tell me in writing.  What are you going to send to me?” 

Obviously, this presumes that you have something easy to send to providers and patients that summarizes utilization management procedures and requirements.  If these procedures are embedded in a larger document that you do not want to send, I recommend that you have a ready supply of copies of that section of the document available for your staff members to send out to requesting providers and consumers.

UM 7 provides:

For initial screening, the organization limits use of non-clinical administrative staff to:

(a) Performance of “review of service requests” for completeness of information;

(b) Collection and transfer of non-clinical data;

(c) Acquisition of structured clinical data; and

(d) Activities that do not require evaluation or interpretation of clinical information.

The standard is weighted “4”, and subsections (a) and (d) are primary elements.

Important relevant defined terms include:

• Initial Screening.  Automated or semi-automated screening of requests for authorization that may include: (1) collection of structured clinical data (including diagnosis, diagnosis codes, procedures, procedure codes); (2) asking scripted clinical questions; (3) accepting responses to scripted clinical questions; and (4) taking specific action (certification and assignment of length of stay explicitly linked to each of the possible responses). It excludes: (1) applying clinical judgment or interpretation; (2) accepting unstructured clinical information; (3) deviating from script; (4) engaging in unscripted clinical dialogue; (5) asking clinical follow-up questions; and (6) issuing non-certifications.

• Nonclinical administrative staff.  Staff who do not meet the definition of health professional (including intake personnel).

• Health professional.  An individual who: (1) has undergone formal training in a health care field; (2) holds a license in a health care field issued by a state and the license allows the professional to practice within the scope of the license without the supervision of another licensed professional; (3) has professional experience in providing direct patient care; and (4) holds a post-secondary degree in health care. A postsecondary degree is defined as any college, university, or nursing school diploma obtained after graduating from high school (nursing diploma or associates, bachelors, masters, or doctorate degree). 

• License.  A license or permit (or equivalent) to practice medicine or a health profession that is (1) issued by a state regulatory body or jurisdiction in the United States; and (2) required for the performance of job functions.

• Review of service requests. Review of information submitted to the organization for health care services that do not need medical necessity certification nor result in a non-certification decision.

• Structured clinical data.  Clinical information that is precise and permits exact matching against explicit medical terms, diagnoses or procedure codes, or other explicit choices, without the need for interpretation.

This standard is the first of a trio of standards designed to set clear restrictions on the use of non-clinical personnel in the review process.  As the Program Guide notes, it applies to all review processes, regardless of the degree of automation, that do not involve clinical judgment and that do not result in non-certification determinations.

Documentation for desktop review includes a very clear policy and procedure that explicitly outlines the responsibilities of non-clinical review staff, their reporting relationships, and scope of work.  Job descriptions and organization charts are also useful documents for submission on AccreditNet.    It also is a good idea to submit sample scripts or algorithms for non-clinical review.

The on-site review will focus on interviews, demonstrations of any automated systems, and a review of sample scripts or algorithms.  More importantly, the URAC reviewer will be examining case files or evidence that the policy and procedure regarding non-clinical staff involvement is strictly followed.

Do not be misled by the fact that the standard is weighted “4”.  It is inextricably linked to UM 9, which is weighted “5” and is therefore a mandatory standard.  Problems with compliance with UM 7 likely will trigger noncompliance with UM 9, destroying any chance your organization has of attaining full 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.

UM 19 provides:

For concurrent review, the organization adheres to the following time frames:

(a) For reductions or terminations in a previously approved course of treatment, the organization issues the determination early enough to allow the patient to request a review and receive a review decision before the reduction or termination occurs: and

(b) For requests to extend a current course of treatment, the organization issues the determination within:

(i) 24 hours of the request for a utilization management determination, if it is a case involving urgent care and the request for extension was received at least 24 hours before the expiration of the currently certified period or treatments; or

(ii) 72 hours of the request for a utilization management determination, if it is a case involving urgent care and the request for extension was received less than 24 hours before the expiration of the currently certified period or treatments.

The standard has a weight of “4” and all elements are primary. 

A few definitions are in order here:

• Concurrent Review: Utilization management conducted during a patient’s hospital stay or course of treatment (including outpatient procedures and services). Sometimes called “continued stay review.”
• Case Involving Urgent Care: Any request for a utilization management determination with respect to which the application of the time periods for making non-urgent care determinations a) could seriously jeopardize the life or health of the consumer or the ability of the consumer to regain maximum function, or b) in the opinion of a physician with knowledge of the consumer’s medical condition, would subject the consumer to severe pain that cannot be adequately managed without the care or treatment that is the subject of the case.
• Utilization Management:  Evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan; sometimes called “utilization review.”

The required documentation is relatively straightforward: a policy and procedure describing your process, and a sample template of a written notice to the patient.  The on-site review, while straightforward, is substantially more rigorous: the reviewer will go through case files to make sure that you are meeting all of these timelines.

A few other pointers are worth noting.  First of all, this standard applies both to inpatient and outpatient services.

Second, UM 19(a) applies to all terminations or reductions in previously approved services.  So, it applies not only to a decision to send the patient home from the hospital sooner than you originally certified, but also to shorten outpatient treatments such as physical therapy to a lower number of visits or a shorter time period for those visits.

Third, UM 19(b) applies specifically to situations where a patient and/or the ordering provider ask for an extension of inpatient or outpatient services before the end of the originally-approved services.  One tricky question is not explicitly covered by the standard, that is, where the patient or provider, in a case not involving urgent care (e.g., physical therapy) , asks for an extension of services before the last of those services has been provided.  For example, imagine that your organization has approved six physical therapy visits, and before the sixth visit, the patient or provider asks for another four visits.  Nothing in the standard specifically addresses of this situation.  However, in our experience, it is a safe bet that the reviewer will interpret UM 19(b) this way:

1. Urgent and received at least 24 hours before certification expires: within 24 hours of receipt of the request
2. Non-urgent and received at least 24 hours before certification expires: within 72 hours of receipt of the request
3. Urgent or non-urgent and received less than 24 hours before certification expires: within 72 hours of request.

As with all issues regarding utilization management time frames, it is worth spending some time with the interpretive information in the Program Guide.  The tips I provide here, as extensive as they are, only scratch the surface of what you need to know to clear this hurdle.

Are your policies and procedures describing your non-certification appeals process available upon request to any patient, provider, or facility rendering service?

If you answer "yes" to this question, you're only partly on your way to meeting the requirements of URAC Health Utilization Management standard 30. One more question to go:

Does your P&P say that it's available to any consumer, provider, or facility?

If you say "no" to this question, it's time to revise your policy.

HUM 30 provides, in relevant part, that:

The organization maintains a formal process to consider appeals of non-certifications that includes:

* * *
(b) Written policies and procedures that:

* * *
(iii) Are available, upon request, to any patient, provider, or facility rendering service. (Primary)

Remember, in the world of URAC (or any other accreditation program), if it isn't documented, it isn't happening. So, it is not merely enough that you P&P is available, but it must say that it's available. And, you must submit this documentation with your application in order to avoid getting a comment from your reviewer asking for more documentation.

One more thing: This is a primary element of a mandatory standard, so failure to provide this documentation could cost you the full accreditation you're hoping to earn.

This standard (UM 3) reads:

The organization maintains processes to: (Secondary)

(a) Receive communications from providers and patients during the business day and after business hours; (Primary)

(b) Respond to communications within one business day; and (Secondary)

(c) Conduct its outgoing communications related to utilization management during providers' reasonable and normal business hours, unless otherwise mutually agreed. (Secondary)

This standard is anomalous because it uses business days, not calendar days, as its metric. This makes sense, however, since it covers only administrative communications, not communications covered elsewhere in the standards (especially requests for review determinations), and because the standard emphasizes that communications should take place during reasonable and normal business hours.

The key here is to articulate clearly all the various ways you receive administrative requests, what mechanisms are in place to receive them after hours, and that you’ll respond within one business day during business hours. The applications we’ve seen more frequently leave out the “after hours” component than anything else, so don’t overlook it!

Finally, the clause in the “Evidence for Meeting the Standards – Desktop Review Materials” section that reads “Include in written documentation that WCUM staff will verbally inform callers of WCUM requirements and procedures” seems misplaced. First, it refers to WCUM, but this is a HUM standard. Second, it applies to a requirement of HUM 4, not 3, so the P&P you submit to demonstrate compliance with this point should be associated with HUM 4.