The Basics

This straightforward standard simply requires that the CM program implement P&Ps for dispute resolution within the program over issues concerning consumers' care options.  

This standard anticipates that reasonable minds within a CM program may differ about what is the best choice for a consumer's care.  It also anticipates that this disagreement could occur among and between any members of the CM care team, including providers.

Be sure to be familiar with your organization's dispute resolution mechanism.  Because URAC doesn't specify what it must look like, it is likely to be unique to your organization.

Management Tips

The standard isn't particularly prescriptive about what this dispute resolution mechanism should look like.  The program guide does hint at the possibility that the mechanism might lean on automated clinical decision tools, but other than that, it is mute on its content.

URAC Accreditation Tips

The initial documentary submission to URAC should include, as always, the P&P describing the mechanism.   The onsite review will focus primarily on interviews with CM staff at all levels, to be sure that the P&P has been implemented.  The reviewer is likely to ask questions soliciting examples in which the mechanism was employed to resolve in-house disputes over care options.

CM 20 carries a weight of 3.