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

While the previous standard described what must not be in your provider agreements, this standard prescribes what must be in your provider agreements.  It is a rather straightforward checklist:

• the names of the parties to the agreement
• minimum requirements for participating providers
• the contractual obligations of both of the parties to the contract
• events that may lead your organization to modify or terminate the provider's participation in the network
• terms regulating your organization's access to consumer medical records in the possession of the participating provider
• the healthcare services that the participating provider will provide under this agreement
• claims submission requirements and prohibitions (e.g. billing of consumers)
• provider payment methodology and fees
• a description of the provider dispute resolution mechanism
• contract term and termination procedures
• terms describing requirements regarding confidentiality of patient health information
• an antidiscrimination clause

Management Tips

Your provider contracting policy and procedure should explicitly require the elements of the standard for all new contracts.  In addition, you should conduct an audit of your present universe of contracts to get a sense of the extent of your organization's compliance with the standard.  Finally, for reasons we will explain in greater detail in a subsequent page, you should replicate nearly all of these requirements in your provider manual, whether or not that provider manual is incorporated by reference into your provider contracts.

URAC Accreditation Tips

About half of these elements are mandatory.  The rest are weighted between 2 and 4.

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

The Basics

This standard prohibits provider contracts from containing either a so-called "gag-clause" or a definition of UM that elevates cost and resource issues over clinical issues.

Management Tips

This standard is quite straightforward, and yet is often missed, at least on desktop review.  It is the classic example of URAC's “it is not enough that you do it right, you must have a policy and procedure that requires that you do it right” philosophy.

Very simply, submitting provider contracts that, in accord with the standard, do not include the two prohibited types of the language, is not enough.  You must also have a policy and procedure that prohibits the inclusion of such language in all provider contracts.  So, in your application, submit both a template agreement and the policy and procedure.

URAC Accreditation Tips

Both elements of this standard are mandatory.

For the desktop review, submit your applicable P&Ps (see Management Tips, above) and sample provider contracts.

The onsite review will involve an examination of between 15 and 30 provider contracts, as well as interviews of provider contracting management staff members.

The Basics

This standard, the first of several standards dealing with contractual arrangements with participating providers, offers the simple requirement that you have written agreements with all of your participating providers.  Naturally, if your organization is contracting with the provider group, you may have a single contract with the entire group rather than each individual participating provider.  However, the underlying point of this contract remains the same: there must be a contractual relationship, embodied in a written agreement, between your organization and every provider in your network.

Management Tips

Although the interpretive materials that accompany this standard don't suggest that this is required, we do recommend that you incorporate the sentiment of this standard into a policy and procedure.  In other words, your policies and procedures should make it clear that every provider must have a corresponding contract.

URAC Accreditation Tips

This is a mandatory standard.

For the desktop review, we recommend that you submit the policy and procedure that incorporates this requirement of a written agreement for every provider.  In addition, that policy and procedure should describe the contracting process and the minimum requirements of those contracts, as spelled out in the next several standards.  In addition, we recommend that you submit a template agreement, one for each category of provider in your network (e.g., primary care provider, specialist, hospital, ancillary provider).  In addition, submit a list of any significant revisions in your provider contracts over the last two years, along with the date and description of each such revision.  Finally, because your provider manual likely will be an important part of the documentation for the next several standards, we recommend that you submit it here.

During the on-site review for this and all the standards in this training section, the reviewer will use your provider manual to select at least 30 participating providers and asked to see the contracts for each.  Make sure that, when you deliver the contracts to the on-site reviewer, it is clear to which of the selected providers each contract applies.  For example, if the name of the provider that the reviewer selects is not on the face sheet of the contract (perhaps because the provider is a member of the group with which the contract is executed) a fix a Post-it note to the contract that bears the name of the provider that the reviewers selected from the provider directory

The Basics

The standard is intended to address the situation of "silent PPOs".  

URAC provides the following definition and explanation of silent PPOs:

[A] PPO brokers access to its provider network to other PPOs or payers without providers’ knowledge.  For example, PPO X may sell access to its provider network to PPO Y.  When an eligible person from PPO Y receives service from a physician in PPO X’s network, PPO Y takes the contract discount, although the physician never signed a contract with PPO Y.

First, if your organization does not operate a silent PPO, this standard is "not applicable."  

Second, it is important to know that this standard does not prohibit silent PPOs.  It simpler requires that you have a process for disclosing to inquiring providers how that silent PPO affects the provider.  That information can be delivered in response to one of two types of questions from the provider:

• First, the provider might be interested to know how a particular claim was paid under your silent PPO or arrangement.
• Second, the provider may want a more generalized understanding of your silent PPO arrangement by requesting a list of clients or other pairs that are entitled to any contract rate under the contract between you and the provider.

If your organization does operate a silent PPO, you will need to find the policy and procedure that describes your mechanism for responding to these two types of inquiries.

Management Tips

If you do have a silent PPO in your organization, you will need to have an explicit policy and procedure that describes how your staff members should respond to the two types of provider inquiries described in this standard.  The policy and procedure should be explicit about what types of information you will provide and who will provide it.  We recommend that you develop a standardized written response to providers who ask for your client/payer list.  In addition, your staff member should be trained in how to answer the question of how a particular claim was paid under the contract.

URAC Accreditation Tips

The two elements of this standard are weighted 4..

In the event of this is a non-applicable standard does you do not operate a silent PPO, you will simply submit an attestation to URAC explaining that you do not operate as a silent PPO.  If you do operate a silent PPO, submit the policy and procedure that describes your response mechanism, along with any standardized template written responses or scripts you prepare for the implementation of that policy and procedure.

During the on-site review, the reviewer will want to look at a list of payers entitled to any contract rate under your contract with participating providers.  In addition, he/she will interview managers in charge of response to provider inquiries described by this standard.

The Basics

As a health plan, your organization communicates with the providers in its network.  This standard sets forth the minimum requirements of your program of participating provider communications:

• a provider communications plan that includes:
  • new provider orientation;
  • network activity updates;
  • information about changes in fees or other contract issues;
  • guidance on getting information about such things as benefits, eligibility of members, formularies, and appeals;
  • guidance on how to obtain provider manuals and similar documents.
• mechanisms to help participating providers navigate your provider network; and
• one more means of receiving suggestions from providers about how you can provide better service.

Most organizations address the standard by developing a comprehensive provider communications plan that not only lists all these requirements, but describes in some detail how your organization meets those requirements.  Check to see if your organization has such a plan.

Management Tips

Our recommendation is that you handle the requirements of this standard by developing a comprehensive provider communications plan that includes all of the above-described elements.  Such a plan should be detailed enough so that a newcomer to your organization, asked to take up responsibility for the execution of some component of this plan, would know, in a general sense, how to do his or her job.

Standardization of your approach to communicating with participating providers could also come in the form of a standard orientation packet that your organization provides to each participating provider.  In addition, provider newsletters are useful means of meeting the requirements of the standard, particularly when developed in the context of a comprehensive provider communications plan.

URAC Accreditation Tips

All of the elements, except for the one requirement a feedback mechanism for providers, are weighted 4.  That element is weighted 3..

You will have a lot of flexibility around the documents you submit in the desktop phase.  Obviously, we recommend that you start with the communications plan described above, and then submit examples of the implementation of the plan, such as provider newsletters, orientation checklists, "blast fax" communications to members of your network, etc.

The on-site reviewer will get most of his or her information about the standard from an interview of provider relations management personnel.  We recommend that, in the course of that interview, provider relations managers be prepared to show the reviewer documentary evidence of the implementation of the communications plan (provider newsletters, orientation package, etc.).

The Basics

Under this standard, your organization must implement a conscious strategy of involving participating providers, at least at some level, in the management of your organization.  In addition, that involvement must include participating providers who are relatively typical of the participating providers in your provider network.  In particular, that participation should involve including participating providers on committees that deal with clinical and provider payment issues.

Typically, a health network complies with this standard by having participating provider representatives on such committees as credentialing, quality management, and utilization management.  Some organizations rely on a multi-purpose committee designed specifically for this purpose, perhaps a physician advisory committee.

Management Tips

Naturally, it is not always easy to get robust participation by physicians and other providers in the management of your company.  If you run into such troubles, just make sure that you document your good-faith effort to recruit providers for participation in your committees.

The standard places an emphasis on participating providers from outside your organization.  Unless your network is a "staff model" organization in which all of your participating providers are employees, you will need to go outside your employee base to find providers who will meet the requirement of the standard.  Within a staff model organization, you'll need to use providers who are not in network management positions.

As is usually the case, it will not be sufficient to merely have participating provider members of committees; your policies and procedures will need to formally create such involvement.

URAC Accreditation Tips

This standard carries a weight of 3 and all its elements are secondary.

At the desktop review phase, submit documents such as 

• policies and procedures that create a role for participating providers on your committees;
• a list of all committee members including providers, making sure to identify provider credentials and relationship to the organization;
• examples of recent committee meeting minutes demonstrating actual involvement of participating providers (again, make sure the participating providers are identified in the meeting roster as non-employees).

During the on-site review, the reviewer will examine committee meeting minutes and interview the medical director about how participating providers are recruited for the organization's committees.

The Basics

This standard requires that your organization, to the extent that your contracts with clients give your organization this responsibility, implements written P&Ps to assure that your consumers have access to:

• covered services that are not available from the providers in your network and
• emergency care, whether within or outside the organization' service area.

The organization no doubt has a policy and procedure on how to handle such a situation; make sure that you are familiar with exactly how your organization has decided to handle these two situations.

Management Tips

Your policy and procedure on the two situations described in the standard must apply to any employee in your organization that might be called upon to explain to the consumer the policy.  So, in addition to network management staff, you likely need to make certain that your customer service representatives who deal with these issues are familiar with your policy.

URAC Accreditation Tips

The two elements of the standard are both mandatory.

For the desktop review, submit both your policies and procedures addressing these two issues and any consumer documents that you use to explain to consumers your policies.  This might be a consumer handbook or sample letters to consumers.  In addition, at this stage you should submit sample scripts for your customer service representatives.

During on-site review, the reviewer will interview your network management staff, and perhaps also your customer service representatives, to make sure that they understand how to handle inquiries regarding both issues.

The Basics

This standard requires that your criteria for selecting providers to participate in your network address quality of care and service requirements.  In addition, you should have criteria that allow you to exclude otherwise eligible providers from your network should business reasons apply.

The quality requirements are relatively straightforward.  For quality of care, most URAC applicants submit their credentialing requirements, such as valid, unrestricted license in the applicable state, current DEA certificate (if applicable), appropriate education and training for specialty, board certification in specialty, proof of liability insurance or self insurance, good standing with Medicaid and Medicare, etc.  For quality of service, we usually see requirements regarding responsiveness of the provider’s office staff, cleanliness of the provider’s office, hours of operation, and the like.  

The "business reasons" element is a bit trickier for some.  As URAC's interpretive comments note:

NM 3(c) is intended to allow the organization flexibility in not accepting providers that otherwise meet the criteria for quality and service.  For example, if the organization already has enough qualified primary care providers, it might not accept another qualified primary care provider based on business needs.

Make sure your documentation gives you the flexibility to say "no" if your network is full in that specialty or some other business reason has you want to restrict a network (except, of course, if you operate in a state with an "Any Willing Provider" law).  

URAC Accreditation Tips

The quality of care and service elements of the standard are mandatory; the business needs element is weighted 4..

Your initial documentary submission should include the documents that establish these minimum requirements for inclusion in the provider network, whether they be P&Ps, a credentialing plan, or some other official organizational document.  

The onsite review will involve management interviews to assure an understanding of the organization's policies on all three elements.

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.