The Basics

This standard requires that the CM program use a clear set of criteria to trigger the case management process for a consumer.  In other words, the program's P&Ps must clearly articulate how individuals are identified for participation in the program.   So, be sure to be familiar with how your organization's P&Ps do that.

Management Tips

This requirement of a clear set of criteria fo inclusion in the CM program applies even if the triggering event seems to be in the hands of a payer or other outside entity.  In many situations, such an entity has a contractual relationship with the CM program that describes a process by which the payer notifies the program of the identity of individuals who will be participants in the CM program.  In such situations, URAC requires that the CM program's P&P address this relationship.  

URAC Accreditation Tips

In addition to the applicable P&Ps, the CM organization also should submit a list of any contracts of the sort described, above, that trigger the case management process for an individual.

In addition to conducting the interview of case managers for their understanding of the criteria, the reviewer conducting the onsite review will examine case management files to assure that the criteria were properly and consistently applied to program participants.