The CMS standard provides:

The MAO must have written policies and procedures and a process for rules of physician participation and adverse participation decisions.

The Basics

URAC supports this standard with the provider dispute resolution standards addressed elsewhere.  The primary change to those standards for the purposes of Medicare Advantage is the requirement that a majority of the members of the appellate review panels be peers of the disputing provider (MAP-NM 1).  In addition, the organization and the contracting provider must provide written notice to each other before terminating the provider agreement without cause (MAP-NM 2).  

URAC Accreditation Tips

Documents you should submit for desktop review include applicable policies and procedures, credentialing committee minutes, provider manual, and a sample template termination or suspension notice to a provider.  In addition, be prepared to submit a list of terminated or suspended providers at this stage.

The on-site review interview will be directed at the medical Director and the members of the staff of the credentialing and provider relations departments.  Questions will include:

• What are the conditions of participation? 
• Is this in the contract language and or provider contract?
• When changes are made how and when are providers notified 
• What are some of the reasons that determine termination, suspension from the network?
• How are these instances investigates and does the credentialing committee make the determination?
• When providers are terminated or suspended from the network what is the process for investigation, notification, and appeal rights?
• Please provide example of quality of care reviews that resulted in termination and suspension. 
• Please show me the cases and documented letters.
• What are reportable event to the medical board?