The Basics

This standard, which is an extension of the Core module's requirement of a clear policy for handling consumer complaints, contemplates the very real possibility that your CM program is only one component of a larger set of programs within your organization, or that it works with/for other organizations.  What this standard adds to the Core requirements surrounding consumer complaints is that you have a documented process for distinguishing between complaints that relate to the CM program and those that relate to other programs in the organization or to other organizations with which your program works.  Once you have made that determination, your process needs to make sure that the complaint gets to the right place, i.e., that the CM complaints go to the person and/or process for resolving CM issues, and that the non-CM complaints a routed to the appropriate persons for the handling of such complaints.  In other words, make sure you have a process to assure that a complaining consumer is routed to the right person and doesn't fall through the cracks between the CM program and the rest of the organization.

Management Tips

Two examples may help to clarify this standard and help you write appropriate P&Ps for it.  First, assume your CM program is a component part of a larger organization, perhaps an insurer.  A consumer complaint comes in, and perhaps is routed by the customer service representative that takes the call to the CM program.  Your P&P needs to guide the person in the CM program on how to make sure that this is a CM complaint, how to handle it if it is, and where to send it if it isn't.  This easily can happen within integrated medical management departments that conduct both utilization management and case management (and perhaps even disease management) within the same office.  Make sure that you know how URAC sorts out this three functions and that calls are routed to the proper person(s).

A second situation might be that your CM program contracts with several plans or insurers.  Consumers may be confused about which organization to call with a particular complaint, and may call you instead of the insurer for a complaint about, say, benefits, which is more properly within the realm of the insurer.  Your P&P needs to anticipate that type of call, and guide staff members in your organization on how to handle the call.

URAC Accreditation Tips

So, in addition to your P&P, what documentation will URAC expect to see?  The best way to handle this would be through a well-constructed complaint log.  This log is no different than the one you'll need for the corresponding Core module standards, but the implication of this standard is that your log will have the capacity to distinguished CM-related calls from non-CM related calls, and track to whom the call was referred.  Also, if you have any correspondence, particularly in the form of template responses to complaints, submit these with your initial submission, as well.  

As you may recall, complaint and appeals reports need to be submitted to the QM committee.  So, it makes sense here to submit documentation that your reports to the QMC include the reporting of how these two types of calls have been handled during the reporting period.  

Remember, make sure everybody is trained on what your P&P says to do about these two types of calls, and that your documentation supports your assertion that you are complying with your own P&P.