The Basics

This standard requires that, in addition to the QIP described in the previous two standards, you also have preventive care programs that include both preventive health guidelines that are age-specific for your organization's entire consumer base, and the dissemination of those guidelines to participating providers.  These guidelines can be either developed externally and adopted by your senior clinicians or developed and approved internally by qualified clinicians.

Management Tips

Your P&Ps on this topic should clearly spell out the development, review, and approval processes for preventive guidelines.  In addition, it will be important that they clearly mandate dissemination of those guidelines to participating providers and describe the mechanism for such dissemination.

URAC Accreditation Tips

For the desktop review, submit your P&P as well as a sample of both the preventive guidelines and evidence of how you provided those guidelines to members of your provider network.

During the onsite review, the reviewer will examine your documentation of review and approval of your guidelines, and will interview senior clinical leadership about that process.

The Basics

These standards require that at least one of the quality improvement projects ("QIPs") required by P-QM 1 focuses on the prevention of acute or chronic health conditions.  The project submitted under the Florida Addendum needs to target populations with the greatest needs and must be in an area where your organization has a good chance of improving quality.

Management Tips

Documentation will be very important, so set up a standardized way of tracking QIPs.  URAC provides a form for this purpose that captures all the essential requirements.  Also, the involvement of the quality management committee in the approval and tracking of your QIPs will need to be documented in that committee's minutes.

URAC Accreditation Tips

All you need to submit are your QIP description forms.  You may also submit QM committee minutes showing committee approval of the QIPs, although that submission can wait for the onsite review if you are reluctant to submit minutes.

During the onsite review, the reviewer will want to see QM minutes for the last three years, as well as binders/files showing full documentation on the three submitted QIPs. The reviewer also will interview your medical director and senior QM staff members about the QIPs.  Have a PowerPoint presentation that summarizes your QIPs.  The essentials for that presentation are:

• definitions of measures (clear descriptions of the numerator and denominator of any fractions/percentages you provide)
• baseline -- date and measure
• goals -- in the same units of measurement as the baseline measure
• time line for achievement of goals
• interventions
• remeasurements. 

The Basics

These standards require that your organization, as a part of the initial credentialing process for PCPs and high-volume specialists, conduct an onsite review of the providers' offices or facilities.

The reviewer conducting the review must:

• carry a photo ID with his/her full name;
• carry identification that includes your organization's name, and
• schedule the review at least 5 business days in advance unless the provider agrees to a shorter notice.

The reviewer must use a review tool that addresses:

• patient access (including both access for the disabled and ability to get appointments in a timely manner); and
• the provider's P&Ps about infection control, hazardous materials, medication; fire safety, emergencies, laboraty, and maintenance of medical equipment.

The reviewer must give to the provider the review standards and/or the review process upon request.  

At a minimum, the onsite review should include a random sample of one consumer medical record to insure that the record is well-organized, complete, and in a consistent format.  In addition, there must be proper documentation and relevant information as described in the previous standard.

Management Tips

Be sure all the required components of these standards are included in your P&P on intial credentialing onsite reviews.  In addition, it will be incumbent on you to make sure your staff is well-trained on those policies and on the URAC standard giving rise to those policies.

URAC Accreditation Tips

For the desktop review, provide the P&P as well as the onsite credentialing audit tool.

The onsite review will involve an examination of files demonstrating compliance with the standard as well as an interview of both credentialing managers and staff members who conduct onsite credentialing reviews.

The Basics

This standard simply extends the requirements of P-CR 1-17 to all the allied health professionals in your network.  

Management Tips

Make sure your Florida credentialing policies include allied professionals.

URAC Accreditation Tips

For the desktop review, submit that portion of your credentialing plan and/or P&Ps that explicitly include allied professionals in your credentialing processes.

The onsite reviewer will simply add allied professionals to his/her expectations of whom you'll credential under your provider credentialing policies.

The Basics

This standard outlines the requirements for your organization's P&Ps assuring that your participating providers keep proper records on your consumers.  The records must:

• be complete and organized
• be maintained consistently and contain
  • the consumer's name and ID number on each page,
  • a record of significant illnesses and conditions,
  • a list of allergies and reactions to medications,
  • medical history,
  • diagnoses that are consistent with the provider's findings, and
  • treatment plans that make sense in light of the diagnosis.

Management Tips

Naturally, your P&Ps will require that you provide your participating providers with your expectations regarding how they keep medical records.  Make sure you document how you communicate those expectations to providers.

In addition, your P&P should address how you will perform periodic audits of your high-volume providers to make sure they are fulfilling your expectations.  Again, make sure you have a sound mechanism for documenting your audits.

URAC Accreditation Tips

For the desktop review, submit your P&P regarding medical records.

The onsite review will be conducted by a physician who will examine 50 medical records from high-volume participating providers.  Talk to your lead URAC reviewer about the method for selecting and preparing those files.

The Basics

This standard requires that health plans have three quality improvement projects ("QIPs") as described in the Core module, rather than the usual two projects.  At least two of these projects must be clinical quality projects.

By "clinical quality", URAC means projects dealing with prevention or care of acute or chronic conditions, high-volume and/or high-risk services, and continuity and coordination of care.  This is to be distinguished from non-clinical projects such as those dealing with access and availability of services, appeals and grievances, and the like.

Management Tips

Not only should you be doing three QIPs at all times, but your P&Ps should specify you have three QIPs appropriate for submission to URAC.  Remember, while you may be doing many QIPs at any given time, not all will be appropriate for URAC submission.  

Documentation will be very important, so set up a standardized way of tracking QIPs.  URAC provides a form for this purpose that captures all the essential requirements.  Also, the involvement of the quality management committee in the approval and tracking of your QIPs will need to be documented in that committee's minutes.

URAC Accreditation Tips

This is a mandatory standard.

All you need to submit are your QIP description forms.  You may also submit QM committee minutes showing committee approval of the QIPs, although that submission can wait for the onsite review if you are reluctant to submit minutes.

During the onsite review, the reviewer will want to see QM minutes for the last three years, as well as binders/files showing full documentation on the three submitted QIPs. The reviewer also will interview your medical director and senior QM staff members about the QIPs.  Have a PowerPoint presentation that summarizes your QIPs.  The essentials for that presentation are:

• definitions of measures (clear descriptions of the numerator and denominator of any fractions/percentages you provide)
• baseline -- date and measure
• goals -- in the same units of measurement as the baseline measure
• time line for achievement of goals
• interventions
• remeasurements. 

The Basics

This standard requires that your organization implement a process to give consumers access to an independent review process that they can access after they have exhausted all the internal appeals mechanisms.  

"Independent review" means "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."  So, once a consumer has gone through all the appeal mechanisms that your organization offers (including those needed to comply with URAC standards HUM 30-36), if coverage is still denied, they can go to through this independent process.  Typically, this is through an "independent review organization" ("IRO") which, in most states, is either an organization that is hired by your organization to conduct such a review, or an agency or process provided by the government (either state or federal).  Make sure you know which is the case for your organization.  It may even be that your organization refers its commercial business consumers to a private IRO and its Medicaid, Medicare, or other government business consumers to a government-provided independent review process.

This standard imposes five basic requirements on the independent review process provided by your organization.  IROs must:

• use appropriate experts to make the determinations;
• have no direct financial interest in either your organization or the outcome of their decision;
• make non-urgent decisions within 30 days of the initiation of the independent review process by the consumer;
• make urgent decisions within 72 hours; and
• may not have been involved in the original decision that is under appeal.

Management Tips

This is an oft-regulated area, with both state laws and government purchasers of health plan services having independent review requirements.  Be sure your P&Ps cover all the possible independent review process that apply to your organization.  

At the very least, the independent review process must be available to consumers appealing decisions of medical necessity and denials based on the decision that the care is investigational or experimental.  

We recommend that you establish a separate tracking mechanism for cases that go through an independent review process.  In addition, if your organization operates in multiple jurisdictions and/or has government clients (e.g., Medicare or Medicaid), you should have a table available to all affected employees that outlines the various independent review requirements.

URAC Accreditation Tips

This standard hastwo mandatory elements and four elements weighted 4.

For the desktop review, submit your P&Ps outlining the independent review processes.  In addition, submit a sample template letter for adverse appeal determinations that describes the availability of the independent review process and the steps required to start such a process.  Finally, provide a report of all your independent review cases from the last year.

The onsite review will involve an examination of a sampling of case files showing how you've implemented the independent review process.  In addition, your medical director and senior utilization management staff will be interviewed by the URAC reviewer regarding the independent review process.

The Basics

This standard requires that your organization respond to the needs of your consumers by implementing a mechnism to ask for and respond to consumers' ideas about how your organization can better serve consumers.  To meet this requirement, your organization may take one or more of several approaches, including conducting satisfaction surveys and developing consumer materials that encourage consumers to call with suggestions. 

Management Tips

A robust consumer suggestion collection system will address multiple means of communicating with your organization, including telephonic, eveluation cards, and surveys mailed to individual consumers, to name just a few.

However, you'll need more than just suggestion-collection.  Rather, you'll need to take it a step further and actually do something with those suggestions, including

• keeping a suggestion log;
• tracking responses to consumer suggestions; and even
• implementing a policy change in response to consumer feedback.

Make sure your applicable P&P addresses all of these elements of a robust consumer suggestion approach.

URAC Accreditation Tips

This standard is weighted 3.

For the desktop review, provide a variety of sample documents in addition to your P&Ps or Communications Plan, including survey results, correspondence with consumers (including newsletters), and an analysis of consumer satisfaction survey results, along with evidence that the analysis was presented to the quality management committee.

The Basics

This standard requires that your organization provide its consumers with on-line access to your organization's information.  Typically, this involves such features as the provider directory, a description of benefit plans, and contact information with phone numbers for consumers to call.  It also might involve providing consumers with their rights and responsibilities, health tips to facilitate self-care, and a summary of benefits, to name just a few possibilities.

Management Tips

It will not be sufficient to have a Web site.  In addition, you should have P&Ps that guide the development, review, and maintenance of that Web site.  Those P&Ps should also describe any necessary precautions to preserve consumer confidentiality.

URAC Accreditation Tips

This standard is weighted 4.

For the desktop review, provide your written P&Ps, as well as the URL of you organization's Web site so the reviewers can see the site for themselves.

The onsite review will involve a short guided "tour" of your Web site.

The Basics

This standard requires that your organization providing 24/7 means of access for your consumers and they're treating providers in the event of urgent healthcare issues.  That access needs to be via a toll-free telephone line.  Your organization may address this issue in part by providing for the participating primary care physicians to serve as the organizational representative when your offices are closed.  If your organization does delegate responsibility to non-employees, those representatives must have authority to act as a representative of the organization. Whether that is the approach your organization takes or not, you should be familiar with the policy, and know that the essential point here is that consumers and providers be able to find somebody who can talk on behalf of your organization at all hours.

Management Tips

Make sure your communications plan is explicit on how it handles after hours calls.  Also make sure that your provider contracts support any delegation of after-hours called responsibility.  Your providers must have the authority to bind your organization if they are acting on behalf of your organization under this standard.  Make sure that if a provider does act on your behalf as a delegate, you don't deny the benefit.  An example of this might be if such a provider refers consumer to seek emergency care at a particular facility.  You may not go back later and deny that care.

It is permissible to play a recording after hours to direct consumers to the appropriate health service.

URAC Accreditation Tips

This standard is weighted 4.

For the desktop review, submit your communications plan.

During the on-site review, the reviewer will interview managers in your organization of irresponsibility of implementing this dimension of the communications plan.  In addition, the reviewer is likely to call as a "secret shopper" to be sure that there is 24/7 coverage.