The Basics

CM 13 requires the CMO to implement P&Ps that help it to assure that the health care providers and vendors to whom the case managers refer consumers are appropriate to the needs of the consumer.   Moreover, the case managers are obligated to implement the intent of the P&Ps and this standard, that is, to make sure that any time you involve a vendor in the care of a patient, you've given appropriate thought (and documented your thinking) about why that vendor is appropriate for this particular patient/worker.

Management Tips

The P&Ps should address how the organization monitors the performance of such providers and vendors.  That monitoring process should include a mechanism for case managers to report sub-standard performance by providers or vendors.  In addition, the P&Ps should describe the procedures for referring consumers to providers.

If the CM program is affiliated with a health plan or network, the P&Ps should deal with referrals to both in-network and out-of-network providers.

URAC Accreditation Tips

The P&P is the only documentation the organization needs to submit for purposes of the desktop review.  The onsite review will involve both interviews of case managers about the referral process and evidence in the QM committee minutes that the quality of providers is a topic of discussion at QM committee meetings.