This CMS standard provides:

The MAO has written standards for timeliness of access to care and member services that meet or exceed such standards as may be established by CMS, continuously monitors its provider networks’ compliance with these standards, and takes corrective action as necessary. The MAO ensures that the hours of operation of its providers are convenient to and do not discriminate against members. When medically necessary, the MAO makes services available 24 hours a day, 7 days a week.

The only URAC standard other than normal health plan contracting standards that URAC provides to support the CMS standard is MAP-NM 15.

The Basics

The standard requires that your organization implement standards requiring members of your provider network to consider input from the Medicare beneficiary in the provider's treatment plan.  Your organization probably carries this requirement in the provider contract, provider manual, or policies and procedures that are binding on members of your provider network.  Be sure you know which documents do this.

Management Tips

In the policy and procedure governing provider care of your members, be sure to be explicit in requiring that they incorporate beneficiary input into treatment plants.  It also makes sense to include this in provider contracts and or documents that are referenced in the provider contract, such as the provider manual or applicable policies and procedures.  In addition, your network management staff should be well-trained on the requirements of this standard.

URAC Accreditation Tips

For desktop review, submit applicable policies and procedures, language from the provider manual and provider contracts, as well as any provider newsletter articles that mention beneficiary input into treatment plans.

The on-site reviewer's interview of network management and customer service staff members are likely to move across the full range of access and availability issues, including standards for urgent and routine appointments, how access and availability is measured, whether provider availability surveys are conducted, and whether issues raised by the standard have ever come up in any consumer complaints.  The on-site document review will involve the reviewer's examination of at least 30 provider contracts, designed to find whether this requirement is included in those agreements.  Be sure to have those contracts marked and tabbed so that the appropriate contract language is easy for the reviewer to find.

The Basics

This standard sets forth requirements for establishing goals and measuring performance for access and availability to providers.  However, our experience is that it is not written in a way so as to convey the full breadth of the requirement.  So, rather than repeat the standard here, I'll give you my version, which, I believe, more accurately captures what URAC seeks:

(a) With respect to access (i.e., geographic dispersion or travel time) of providers to provide care to consumers, the organization: 
    (i) Establishes goals; 
    (ii) Measures actual performance in comparison to those goals: and
    (iii) Makes improvements where necessary for the provider network.
(b) With respect to availability of providers to provide care to consumers (i.e., ability of consumers to receive care in a timely fashion), the organization: 
    (i) Establishes goals; 
    (ii) Measures actual performance in comparison to those goals: and
    (iii) Makes improvements where necessary for the provider network.
(c) The organization reports the measurements described above to the quality management Committee.

If you think about the standard this way, you are far less likely to make the most common NM 2 error, to submit documentation that relates only to geographic dispersion, and not the ability of consumers to receive care in a timely fashion.

Management Tips

So, what kind of documentation are we talking about here?

For “access”, since your goals will be expressed either geographically (e.g., “2 providers per specialty per county”) or drive-time (e.g., “no more than 30 minutes drive to a primary care provider in urban areas and no more than 45 minutes in rural areas”), documentation of measurement of your performance against those goals will be in the form of a GeoAccess or similar report.

On the other hand, for “availability”, since your goals will be expressed in terms of hours of availability (e.g., “office open at least 30 hours per week”) , wait times for appointments (e.g., “no more than a two week delay for a non-urgent appointment”),  or customer satisfaction regarding the ability to receive care in a timely manner (e.g., “85% customer approval of provider availability”),  documentation of measurement of your performance against those goals should include consumer surveys (like CAHPS), the results of so-called “Secret shopper” calls to your providers, and reports from your onsite visits to providers' offices.

As much as is humanly possible, however, in any event, you should strive to present performance measurement in the same units of measurement as you express your goals for both access and availability.

URAC Accreditation Tips

The three elements of this standard are weighted either 3 or 4..

For the desktop review, submit a P&P and/or program document that outlines how you establish goals and measure performance regarding access and availability.  In addition, submit one or two sample reports (or portions of sample reports) for both access and availability.

The onsite review will involve both an interview of management personnel and an examination of your full access and availability reporting.

The Basics

With this standard, you are required to answer the question, what services do we provide, and where do we provide them?

This standard is important to URAC reviewers, because it helps them understand the nature of your network.  Are you a general healthcare services network or specialty network?  Do you provide health care services in a small region, statewide, or nationally?  The rest of the review will be guided by the documentation and answers to interview questions that you provide in connection with this standard.

Your organization likely answers both of these questions in official documents, such as marketing documents, regulatory filings, and the geo-access maps that help you manage your provider network.  Make sure you are familiar with how your organization officially answers these questions.

Management Tips

Remember, it you do not get credit for doing things that you do not document.  So, the fact that you operate in a certain area and provide certain health care services is insufficient for purposes of this accreditation process.  Rather, you need to be able to document, with official company documents, what services you provide and where you provide them.  You are allowed a good deal of flexibility in how you do this.  Your documentation might be in marketing materials, regulatory materials, internal policies and procedures or plans, or reports.

URAC Accreditation Tips

Each of the two elements of this standard is weighted 4.

Your desktop review documentation is likely to be some combination of plans (business, marketing, strategic), service area maps, geo-access analyses, and regulatory filings.

The on-site reviewer will verify your compliance with the standard through an examination of your organizational documents and interviews with network management and provider relations management personnel.

This CMS standard provides:

The MAO maintains and monitors a network of appropriate providers that is sufficient to provide adequate access to and availability of covered services.

The URAC standards implementing this standard are discussed at the links, below.

This CMS standard provides:

An MAO may not discriminate, in terms of participation, reimbursement, or indemnification, against any health care professional who is acting within the scope of his/her license.

The URAC standard that implements this standard is URAC MAP-AD3:

The Basics

This simple standard requires that your organization not discriminate against practitioners or any other healthcare professionals who are practicing within the scope of his or her respective license or certification under state law, solely based on the practitioner's or provider's license or certification.  In addition, the organization must give a reason -- in writing -- for declining to include a particular provider or group into the network.

Your organization likely has an anti-discrimination clause in its provider contracts and, likely, its provider manual.  In addition, an antidiscrimination clause may be in a credentialing policy and procedure or credentialing plan.  Make sure you know where all your organization's anti-discrimination clauses are located.

Management Tips

While it is true that you no doubt have anti-discrimination language somewhere in your documents, make sure that the particular kind of discrimination that is the subject of this standard -- discrimination based on license or certification -- is explicitly addressed in your credentialing plan and/or credentialing policies and procedures.  The most frequent failing of organizations trying to meet this standard is that their antidiscrimination language is not sufficiently specific about this particular kind of discrimination.

URAC Accreditation Tips

As always, the starting point is your credentialing plan and/or policies and procedures.  In addition, any complaints filed with CMS regarding discrimination, and how your organization resolved such complaints, should be submitted.  Finally, a template letter to providers explaining why they were not credentialed or re-credentialed should be submitted.

The on-site reviewer will interview your provider relations and credentialing staff members, as well as your medical director.  Questions that are likely to come up in that interview related to the standard include whether there are any particular specialties that are not allowed to participate in your provider network.  In addition, the reviewer may pose as a provider interested in applying to your network, and ask, from that perspective, how he/she can find out which categories of providers are allowed in your network.  Finally, the reviewer will want to know if you have closed your provider network to any specific provider or providers, and if so, how you notified the provider.  The document review during the on-site examination will include a review of provider contracts and the credentialing files of providers denied from participation in your network.

This CMS standard provides:

The MAO must have written policies and procedures for selection and evaluation of providers and follow a documented process for facilities regarding initial credentialing and recredentialing.

The URAC standard that implements this standard is URAC MAP-NM 3:

The Basics

This standard requires that your organization credential and re-credential facilities in your network by, at least, determining that each facility is licensed to operate in the state and in compliance with all other applicable regulations, and that it is either accredited or meets your organization's standards.

No doubt you will find your organization's policies and procedures complying with the standard in your credentialing plan or similar document.

Management Tips

There is nothing particularly special imposed by this standard above and beyond what URAC already requires you to do with facilities, with the exception of an overt demonstration that your facilities are either accredited or meet your standards.  That being said, it still makes sense to very clearly articulate, perhaps even in the language of this standard, these requirements for your facilities.  In addition, as always, make sure your credentialing staff is well trained in the requirements for facilities imposed on Medicare Advantage plans.

URAC Accreditation Tips

As is the case with most credentialing requirements, submission of your policies and procedures and/or your credentialing plan is an essential start to the documentation submission process.  In addition, for the desktop review, it makes sense to submit information about accreditations that you require of your facilities, as well as sample committee minutes demonstrating the application of your facilities credentialing requirements.

During the on-site review,the reviewer will interview the credentialing and provider contracting staff, as well as the medical director.  Issues covered will be credentialing criteria for both practitioners and facilities, including requirements for licensing, accreditation, Medicare certification, and anything else that applies.  The reviewer is likely to ask under what circumstances you would not recredential a facility.  The reviewer also will incorporate the requirements of the standard into his/her review of 30 provider credentialing files.  In addition, he/she will examine credentialing committee minutes for evidence of compliance with the standard.

The Basics

Under this standard, your organization may not submit a credentialing application that:

• is signed and dated more than 180 days prior to credentialing committee review, or
• has verification information collected more than six months before review.

The purpose of this standard is to make sure that the credentialing committee or senior clinical staff member are reviewing information that is relatively recent.  To accomplish this, your organization must have policies and procedures to move credentialing applications through the credentialing process in a timely manner.

Sometimes, however, credentialing committees review a particular application more than once.  The standard applies only to the first time an application comes before a credentialing committee in that cycle.

If an application should fall through the cracks and have stale data, you need not make the provider go through the entire credentialing process again.  Rather, you may have the provider re-sign the attestation that declares that the information on the application is still valid and accurate.

Management Tips

To help your staff make sure that no stale applications are submitted to the committee or the senior clinical staff person, your checklist or audit sheet for each credentialing file should have an element that allows the staff person checking the application to see whether this application complies with the timeframe requirements of this standard.

URAC Accreditation Tips

The two elements of this standard each carries a weight of 4.

Documents to be submitted in connection with the desktop review should include a credentialing plan that clearly describes the applicable time frames and a checklist or audit form that allows the staff member to confirm compliance with these time frames.

The on-site reviewer will both interview credentialing staff regarding these time frames and examine three dozen or so credentialing files to assure that no stale applications have been submitted to the committee or the senior clinical staff person.

The Basics

Your organization must verify state licensure and board certification (if applicable) or the highest level of education achieved by the practitioner, using primary sources.  "Primary source verification" is defined as "verification based on information obtained directly from the issuing source of the credential."

In other words, for these two categories (licensure and board certification or highest level of education), you must obtain written verification from the issuing source that the credential is valid and current.  Most commonly, this involves going to a website maintained by the issuing body and printing off a page that verifies the credential.  In the absence of that, a letter, or a documented phone call (including staff person making the call, date of call, and name of the person at the issuing entity with whom the staff person spoke) will suffice.  Whichever approach you take, make sure that you are following your organization's policies and procedures regarding primary source verification during credentialing.

Management Tips

The key component for management is to make sure that the applicable policy and procedure or credentialing plan addresses the means by which you will use primary source verification processes.  Whatever methods are chosen (website, letter, or telephone), it is essential that the documentation include sufficient information.  For example, for licenses, you must verify not only its present validity, but the expiration date.

If the board certification is of the type that does not expire, it must be verified only upon initial credentialing.  However, if there is a possibility of expiration of board certification, it must be reverified upon re-credentialing.

Make sure that your documentation includes an indication as to which member of the staff is doing the primary source verification.  This is an essential part of the documentation for this standard.

URAC Accreditation Tips

Both elements of this standard are mandatory.

It will be sufficient to provide the credentialing plan at the desktop review phase, so long as the credentialing plan is detailed in its description of the processes used for primary source verification.

Not only will the on-site reviewer examine your credentialing files to assure compliance with the standard, but he or she also will talk with members of the credentialing staff and may even observe members of the staff as they conduct primary source verification.

This CMS standard provides:

The MAO must have a process for health care professionals’ input in the credentialing process.

The URAC standards that support this standard are discussed in the following pages:

This CMS standard reads:

The MAO must follow a documented process for physicians and other health care professionals regarding initial credentialing and recredentialing.

The URAC standard that implements it is P-CR 5, discussed below.

The Basics

The standard describes, in some detail, the requirements for the credentialing application that every practitioner must complete in order to seek admission to your organization's provider network.  Note that this applies only to practitioners, not facilities.

The requirements include:

• educational and professional training history (including Board certification status);
• an up-to-date history of all licensure; 
• documentation of current controlled dangerous substance certificates, federal (DEA) or state;
• documentation of liability insurance;
• liability claims history;
• sanctions history;
• professional disciplinary history (including state boards and Medicare/Medicaid);
• hospital privileges;
• any issues that could impede the petitioner's ability to provide quality health care (including disability or substance abuse);
• an attestation that the application is complete and accurate;
• a statement authorizing your organization to collect verifying information (signed and dated).

Again, this standard applies only to practitioners, that is, the individuals who provide health care services within your network.  The organization has more flexibility about how to design any application for facilities, such as hospitals, skilled nursing facilities, etc.

Management Tips

If your organization uses one of the many standard credentialing applications used across the United States, make sure that it complies completely with the standard.  If it does not, you may need to develop an amendment to collect the information not in that application that is required by this standard.  However, if your organization uses the most current universal credentialing application developed by the Council for Affordable Quality Healthcare (CAQH), that application will comply with the standard.

Electronic signatures will suffice for purposes of this standard.

Make sure that your application requires at least five years of licensure and privilege history from the practitioner.

If you collect a liability insurance cover sheet from your practitioners, make sure that it includes the name of the practitioner, the policy's expiration date, and the liability coverage.  The policy must be current when the practitioner is presented to the credentialing committee.  Note that a provider's attestation is not sufficient documentation of liability insurance, nor is the mere provision of the insurer's name, policy number, amount of coverage, and expiration date.  So, if you don't have a DEC sheet, you'd better get an attestation from the insurer.

URAC Accreditation Tips

The standard carries the weight of four, and most of the elements are primary.

For the desktop review, all you need to present is your credentialing plan (describing the application requirement) and a sample template of your application.

Compliance with the standard will be checked during the on-site review as the reviewer goes through the three dozen or so initial credentialing and recredentialing files that he or she will pull at random, selected from your provider directory.