The Basics

This standard provides:

An MAO may not prohibit a health care professional from advising or advocating on behalf of a patient.

In addition to the URAC standards prohibiting so-called "gag-clauses" in provider agreements, URAC supports this CMS standard with two standards, MAP-NM 5 and MAP-NM 6.  Those standards require that your organization:quotes in

• ensure that participating providers in your network provide information to their patients who are your members in a culturally competent manner; and
• provide consumers with disabilities with effective communications throughout the healthcare system.

The on-site document review will focus on making sure that the contracts with providersdo not contain gag clauses or improper definitions of utilization management.  In addition, provider complaints would be examined to see if there are any problems associated with requirements of the standards.

In addition, your organization is not required to cover, furnish, or pay for a particular counseling or referral service if your organization objects to the provision of that service on religious or moral grounds and provides consumers information, before and during enrollment, about any such constraints on the organization's coverage.  It is important, however, that your organization provides consumers with notification of the adoption of the policy within 90 days.

URAC Accreditation Tips

Documentation for the desktop review includes applicable policies procedures, provider manual, or sample provider or member newsletters.

The on-site interview will be directed at the medical director and provider relations and utilization management apartment staff, and will focus on the following questions:

• How do providers know who to contact when medically necessary care is not available within the plan? 
• What expectation does the plan have for oncologists in informing patients about their treatment options?