The Basics

CM 15 sets forth five categories of information that the organization (typically via the case manager) must disclose to the consumer at the beginning of the CM relationship.  Four of the categories must be disclosed regardless of whether the consumer has requested it, while the fifth must be disclosed only if the consumer requests.

The four categories that must be disclosed regardless of request are:

• The nature of the CM relationship. This kind of information should include whether an insurer or TPA is involved.
• When and how information will be disclosed to others.  Again, this is to make sure the consumer knows whether an organization other than the CM program (e.g., insurer or TPA) is involve, and whether and when such organizations will have access to the consumer's information.
• The rules about written notification.  This disclosure should make clear the circumstances under which the consumer can expect to receive written notification about what is happening in his/her relationship with the CM program.
• The rules about filing complaints.  Echoing the requirements of the Core module's complaints and appeals requirements, this component mandates disclosure that is sufficient to empower the consumer to pursue complaints about the CM program's services.

The one category of disclosure that is tied to the consumer's request is the answer to the question, "why was the consumer selected for this program?"  This rationale might even include relationships between the CM program and other organizations, such as "your insurer, XYZ Co., identified you as being at risk for . . .."

Management Tips

Make sure the P&P gives clear guidance to the case managers about how to document these disclosures.

URAC Accreditation Tips

Documentation for this standard starts, as usual, with the P&P that requires the Program to provide this information.  In addition, though, URAC asks for the submission of documentation of implementation of the P&P, such as the "welcome packet" that some CM Programs send to new participants, or a "Patients' Bill of Rights."

The onsite reviewer will look for evidence of implementation of the P&P in both her interview of case managers and her review of the case files.  There should be clear evidence that the welcome packets, bills of rights, or other consumer notification documents  have, in fact, been sent to all the participants in the program.