The Basics

This standard establishes four requirements for the service that is provided via the customer service toll-free telephone line described in the previous standard.  The services include:

• responses to inquiries about benefit verification and eligibility;
• help with finding providers in your network;
• answers to questions about claims; and
• accepting consumer complaints.

It will be important not only that you are familiar with your organization's policies and procedures regarding how these services are provided, but also the tools used in the provision of those services, such as consumer call logs and any scripts to help with delivering those services.

Management Tips

Make sure your communications plan is explicit on all four requirements of this standard.  The reviewer will reject it on desktop review if it doesn't clearly outline how you address all four issues.  In addition, it is incumbent upon you to provide documentation that you have trained your customer service representatives on how to handle all four types of inquiries.  Finally, while it is not required by the standard, it will help things greatly if you have a comprehensive consumer call log that provide some detail about how each call was handled and resolved.

URAC Accreditation Tips

Two of the elements of this standard are mandatory; the other two are weighted 4.

In addition to the communications plan, on desktop review you should submit customer service representative training records (including agenda and attendance sheets), a sample of your consumer call log, samples of any template correspondents used by the customer services department, and sample telephone statistics.

During the on-site review, the reviewer will both interview and observe customer service representatives taking calls.  During that observation, he/she not only will ask questions of the customer service representative, but also will assess whether the customer service representatives have the appropriate tools to handle all four types of inquiries described in this standard.

The Basics

This standard requires that your organization provide to consumers access to a toll-free line at least 40 hours per week.  That line must be open between 9 a.m. and 4 p.m. each business day in each time zone in your service area.  The only exceptions to that would be time zones in which you have fewer than 2% of your consumers.  Your organization no doubt has a policy and procedure that establishes the specific hours your organization's toll-free line is available.  Make sure you're familiar with it in addition to the standard.

Management Tips

Your communications plan should specify the hours of availability for your toll-free telephone line.  In addition, he should be able to produce documentation demonstrating what percentage of your consumers are in each time zone in your service area.  Furthermore, your communications to consumers should include your toll-free telephone line's hours of operations.  Be sure that your communications plan and those consumer communications agree with each other regarding those available times.

URAC Accreditation Tips

This standard is weighted 4.

For the desktop review, submit your vacations planned or P&Ps specifying your toll-free telephone line's available hours.  In addition, you should submit a sample of consumer communications that provide the hours of that line.

During the on-site review, the reviewer is likely not only to interview your customer service managers about the standard, but also to place "secret-shopper" calls to that number to make sure that you are implementing your policies and procedures.

The Basics

This is standard requires that your communications plan provide that, upon enrollment in one of your organization's benefit plans, a consumer is provided with a means of accessing it a participating provider directory.

In addition, your communications plan must assure consumers of ongoing access to up-to-date participating provider lists.  This might take the form of a phone number to call to talk to a customer service representative, the provider directory on the website, or some similar constantly-updated provider list.

Management Tips

Make sure that your communications plan addresses all of the ways that you provide your provider lists to consumers, both upon enrollment and on an ongoing basis.  Furthermore, it will be important that your customer service representatives are up-to-speed on all the various mechanisms that you have in place to provide such information.  Make sure your training covers it.

URAC Accreditation Tips

The two elements of the standard are weighted 4.

For the desktop review, provide not only your communications plan, but also documentation of the implementation of the plan, such as correspondence with consumers about updated provider lists, a screenshot of your online provider directory, and consumer information with your organization's toll-free number that consumers can call in order to find participating providers.

The on-site review will be an interview of both managers and staff members in the customer service department.  This places a premium on training on the standard and your policies that implement it.

The Basics

This standard requires that your organization's communications plan explicitly provide that you inform consumers before you make changes in their covered benefits.  They must receive the notice before the change goes into effect.

An example of this would be in the event that he changed the copayments on one of your benefit plans.  You either need to send notice directly to the consumer, or have an assurance from the consumer's employer or the plan sponsor that it will give notice to the consumer in a timely manner.

Management Tips

This is one of those standards where it is not sufficient to do the right thing; rather, you must also have a policy and procedure that requires that you comply with the standard and describes how you will do it.

URAC Accreditation Tips

This single-element standard has a weight of 4.

For the desktop review, submit your formal communications plan, a summary listing of all benefit changes in the last two years (including the date of those changes), and sample correspondence to consumers regarding such changes.

During the on-site review, the reviewer will talk to customer service managers to confirm their understanding and implementation of your communications plan.

The Basics

This standard places an affirmative obligation on your organization to include in its consumer communications plan specific provisions on providing consumers with materials to explain:

• how to receive help via e-mail, telephone, or in person;
• covered benefits;
• accessing covered benefits (including prior authorization requirements, special information for emergencies and receiving services when out of the organization's service area, and drug formulary);
• cost sharing mechanisms in your benefits plan;
• instructions on how to find out the cost of covered benefits;
• any responsibilities imposed on the consumer to cooperate with the organization's medical management programs;
• benefit exclusions;
• instructions on how to obtain evidence-based health information;
• directions on how to pursue complaints and appeals.

It will be important that you have access to a current copy of the communications plan and are familiar with how it addresses these issues.

Management Tips

Make sure that you don't rely exclusively on Internet access to comply with the standard.  Not everybody has a computer, and you're obligated to document how you will get this information to folks who don't.

URAC Accreditation Tips

Most of the elements of the standard are either mandatory or weighted 4.  One element, addressing information about the cost of covered benefits, is a Leading Indicator.

Naturally, the communications plan will be the central document that you submit for desktop review.  In addition, the documents that demonstrate compliance with your policies and procedures as articulated in the communications plan, such as member rights and responsibilities documents, newsletters, correspondence, or member handbook would be a good accompaniment to that plan.  In addition, documentation of training of employees and consultants in the requirements of the standard also would be helpful.  Remember, keep the number of documents you submit to nine or fewer.

During the on-site review, the reviewer will examine recent enrollment materials and documentation of how you handle consumer complaints and appeals.  In addition, interviews of marketing and customer service managers and staff members will cover not only their understanding of your policies and procedures, but also how thoroughly they've been trained.

The Basics

This standard requires that your organization make available to consumers a rather extensive and specific list of items of information about your organization and its services:

• a description of the mechanisms by which your organization provides information for consumers for whom English is a second language or who have special needs, such as cognitive or physical impairments;
• a list of network providers;
• general descriptions of your compensation arrangements for participating providers;
• any tools that your organization makes available to consumers to help them in managing their own care;
• statistics about consumer satisfaction with your organization's services;
• administrative requirements;
• requirements regarding medical management (UM, CM, DM);
• health benefits;
• any financial responsibilities that your health plan imposes on consumers, such as deductibles, co-pays, co-insurance, etc.;
• any responsibilities that consumers bear for health benefits decision-making;
• any criteria for benefits that her condition-specific; and
• information about coordination of benefits.

Your organization no doubt has detailed policies and procedures addressing all of these points.  Make sure that you are familiar with those policies and procedures, and not just this standard's requirement.

Management Tips

Notes that you don't have to post all of this information in public places.  For example, you may choose to provide the provider compensation arrangements and consumer satisfaction statistics only upon request.  However, if you take that option, you must make sure that your customer service representatives and any other members of the staff who might be recipients of such a consumer request are fully trained on how to respond to those requests.  Furthermore, the provider compensation information described in this standard does not have to address specific compensation amounts; rather, it may provide a general description (e.g., capitation, fee-for-service).

URAC Accreditation Tips

All of the elements of the standard are weighted 4.

For the desktop review, submit written policies, consumer materials like a member handbook or a summary benefit plans, a portion of the provider directory, a screenshot from your consumer portion of your organization's website, evidence of training in the standards, and the results of consumer satisfaction surveys.  This is a lot, so be strategic so that you keep your documents and to submit to nine or fewer.

The on-site review will involve a thorough documentation review of consumer education materials and the organization's website.  In addition, the interviews will be conducted of senior management, marketing personnel, and customer service managers to assess understanding of all elements of your applicable policies and procedures.  In addition, the reviewer is likely to call your customer service representatives to see if they know how to respond to requests for information covered by the standard.

The Basics

The standard adds details to the more general Core standards regarding marketing your organization's services.  It requires that your organization implement protections to ensure that marketing and sales activities do not misrepresent:

• benefit plans;
• network provider availability and accessibility;
• information about what is covered by your plan, including exclusions and limitations;
• any administrative requirements the consumer needs to know; and
• and medical management (utilization management, case management, disease management) requirements.

Make sure you are familiar with your organization's policies and procedures on this topic.  It will not be enough to know the requirement generally, but rather how your organization implements it.

Management Tips

The organization's policies must apply not only to written materials in both print and on the organization's website, but also to information conveyed to consumers by agents, brokers, and consultants.  The interdepartmental mechanism required of printed and website materials by the corresponding Core standard should be detailed enough to address the more specific requirements of this standard.  In addition, be sure your policies and procedures overtly address how to train agents, brokers, and consultants so that they convey accurate information about your organization to consumers.

URAC Accreditation Tips

Three of the elements of the standard are mandatory; the other two are weighted 4.

For the desktop review, submit:

• applicable policies and procedures;
• training manuals agendas and attendance records for employees, brokers, agents, and consultants;
• 2-3 samples of marketing brochures, along with documentation that they have been approved by the interdepartmental process;
• a screenshot of consumer materials on your realization website.

The on-site review will include a more complete examination of your marketing materials, as well as an interview of both customer service employees and marketing management and staff members.

The Basics

The standard is for the special situation of a provider whose conduct is so egregious as to give rise to a well-founded concern by your medical director that the provider is posing a threat to the well-being of your consumers.  This is a very important consumer safety standard.  Not only must you are medical director be freed from the requirement of taking such a dispute through the normal, often slow, dispute resolution process, it places an affirmative requirement on him or her to handle such a situation in an expeditious manner.

The proper procedure, once the medical director concludes that the provider poses such a danger, is to suspend immediately the provider.  Then, after the suspension, your organization should conduct an expedited investigation to make sure that the medical Director's concerns were well-founded.  Finally, the dispute resolution mechanism described in the previous standards must be made available to the suspended provider.

Management Tips

The requirements of this standard must be embodied in your credentialing plan or a policy and procedure that explicitly contemplates this circumstance.  In addition, your medical director must be absolutely clear that he or she not only has this authority, but also an affirmative obligation to exercise this authority.

URAC Accreditation Tips

All three elements of this standard are mandatory.

For the desktop review phase, you may submit the same documentation that you submit for the previous dispute resolution standards.  

During the on-site review, this issue will come up in the reviewer's interview with the medical director.  He or she must be prepared to answer this question, as it is almost a certainty to come up.  This kind of emergency suspension procedure is fairly uncommon, so it would not be surprising if you had no documented examples.  However, if you do, we recommend that you be prepared to produce one or more examples of such an emergency suspension for the reviewer's examination.

The Basics

After a decade of dealing with provider dispute resolution accreditation standards, we have concluded that it is best to deal with them as a whole, rather than individually.  Under these standards, your organization must have a well-developed mechanism for resolving significant disputes with providers.  Typically, those providers disputes come in two categories, administrative and clinical/professional.  While it is possible that you will have a single provider dispute resolution mechanism for all of these disputes, it is more likely that your organization has chosen to provide different dispute resolution mechanisms for these two categories.  The "due process" afforded to providers in a clinical/professional dispute resolution process is more robust and expensive to administer than the required processes for administrative dispute resolution.

In any event, these standards require that your policies and procedures for provider dispute resolution clearly articulate that process in a way that providers can understand, provide for specific time frames for each step in the process, and have clear descriptions of the process by which providers may seek redress and appeal decisions made in the process.  In addition, these policies and procedures must be developed and reviewed with the involvement of participating providers no less frequently than annually.

The minimum requirements for "due process" for these two types of provider disputes are as follows:

• Clinical/professional (e.g., related to professional quality of care or conduct):
  • two levels of appeal
  • each appeals panel is comprised of at least three persons
  • each appellate panel has at least one participating provider who is not otherwise involved in network management and who is a clinical peer of the disputing provider
  • the provider may present relevant information at each level of appeal, although not necessarily in person
• Administrative:
  • the provider has a mechanism for the presentation of relevant information
  • the provider's issue will be considered by an authorized representative of the organization who was not involved in the initial decision that is the subject of dispute

Management Tips

Nearly all first-time applicants will need to modify their existing policies and procedures to accommodate these standards' requirements, particularly the requirement of having a second-level appellate panel composed of at least three people, one of whom is a participating provider who is a clinical peer of the disputing provider.

Most organizations house these dispute resolution policies and procedures within their credentialing program.  Therefore, this language probably should be in their credentialing plan or credentialing policies and procedures.

Another often-missed requirement of this set of standards is that your policies and procedures for provider dispute resolution be annually approved by participating providers.  This most frequently is met by having the standards come up for annual review by the credentialing committee, which has to review all credentialing policies and procedures in any event on an annual basis.

URAC Accreditation Tips

The elements of these standards are either mandatory or weighted 4..

For all of these standards, you should submit your applicable policies and procedures, as well as any sample correspondence associated with provider dispute resolution.  In addition, it would be helpful to submit minutes from committee meetings demonstrating provider approval of the policies and procedures, as well as any minutes from appellate panels involved in provider dispute resolution.

For the on-site review, you will be asked for a list of complaints, grievances and appeal submitted by providers over the last year.  From that list, the reviewer will select sample provider disputes to a sure that your dispute resolution in those cases was conducted according to policies and procedures and the applicable standards.  In addition, your senior staff members and medical director will be interviewed on how disputes are handled.

The Basics

This standard contemplates that not all of your existing contracts with participating providers contain all of the requirements of the previous several standards.  Rather than forcing your organization to go back and amend all of the extant, noncompliant participating provider agreements, URAC allows you to "fix" to these agreements by using your provider manual or other similar document that describes the relationship between your organization and the providers in your network.  So long as your provider manual contains all of the required provisions of the previous several standards, or, in the alternative, you provide instructions to your providers on how to obtain the documents that incorporated these required elements into your relationship with disputing providers, you need not go back and amend old, noncompliant agreements.  However, note that, on an ongoing basis, your new contracts do need to comply with the previous several standards.

Management Tips

The simplest way to take advantage of this standard is to make sure that your provider manual contains all of the requirements included in the previous several standards.

URAC Accreditation Tips

The two elements of this standard are weighted 4.

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