URAC CM 1 -- Case Management Program Description

CM 1 provides:

The case management program’s description and/or written policies and procedures include a definition of case management consistent with these Standards.

The standard is weighted “4”, and the entire standard is a primary element.

The applicant has some flexibility about what documentation to submit for desktop review. The Program Guide suggests that the reviewer will accept either a policy and procedure or some other document that constitutes a program description. In addition, organization charts and descriptions of case management staff members and their positions should be submitted.

However, we have noted that, at least among some URAC reviewers this year, a tendency to construe quite strictly in the last four sentences of this standard, “consistent with these Standards.” While the Program Guide makes it clear that the “definition of case management does not have to be the same as the definition in URAC’s Case Management Standards,” interpretations by reviewers in some recent reviews suggest that your definition better be pretty close to URAC’s:

A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet a consumer’s health needs through communication and available resources to promote quality cost-effective outcomes.

This should not be surprising, given this language, also found in the Program Guide:

It is extremely important that the applicant’s definition of case management is consistent with URAC’s definition of case management. If you do not have a member centric, collaborative approach model you will struggle to meet the intent of the case management standards.

There is another hint within the Program Guide about the particular language URAC finds important:

If the organization also uses a case manager for making benefits determinations the advocacy role is clearly defined.

The emphasis on “advocacy” is in the Program Guide, and should be considered part of the “tea leaves” used to predict have a reviewer at will apply this standard to your organization’s case management program.

Once you get past the desktop review, however, the on-site review should pose few problems, unless, that is, you have a member or members of your staff not on board with the collaborative approach required by the standards. This is pretty rare in our experience, but is certainly something to emphasize in staff training.