URAC Core 26 -- 28 --- Complaints and Appeals

One set of URAC's Core standards, Core 27-29, spell out requirements for complaints and appeals. They provide:

CORE - 26 - Complaint and Appeal System
The organization maintains a system to receive and respond in a timely manner to complaints and, when appropriate, inform consumers of their rights to submit an appeal.
CORE - 27 - Appeal Process
The organization maintains a formal appeal resolution process that includes:
(a) Written notice of final determination with an explanation of the reason for the determination;
(b) Notification of the process for seeking further review, if available; and
(c) A reasonable, specified time frame for resolution and response.
CORE - 28 - Complaint and Appeal Reporting
The organization reports analysis of the complaints and appeals to the quality management committee.

The question I get most often from my clients about these standards is this: "Does this create appeal rights for all complaints?"

The answer is, "no". The standards are careful to use the phrases "if available" and "when appropriate" when referring to appeal rights. Other URAC standards do grant very specific appeal rights, but not these.

No, these standards simply explain that you must have a system for responding promptly to all complaints, and where you do offer appeal rights, that it be formal, including written notice of final determination, notification of the process for appeal, and reasonable time for resolution. And, don't forget to report periodically to the quality committee!

If you say you have no complaints, URAC's view, articulated at a recent education seminar, is that your employees probably don't know what a complaint is.  URAC's definition is broad: "An expression of dissatisfaction regarding the organization’s products or services."  With a definition that broad, URAC's thinking goes, you should have some complaints in your tracking system.