URAC Core 26 -- Complaints and Appeals, the "Employee and Community" Complaints Issue

In what some veteran reviewers might see as a change in interpretation, it appears that URAC is now including employees in what has previously been seen as a standard designed to protect only consumers.

Core 27 reads:

"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."

Historically, URAC reviewers have read this as referring to consumers, which URAC defines as "An individual person who is the direct or indirect recipient of he services of the organization. Depending on the context,consumers may be identified by different names, such as "member,” enrollee,” “beneficiary,” “patient,” “injured worker,”“claimant,” etc."

Note, however, that "employee" isn't one of the suggested synonyms for "consumer."

So, imagine my surprise when I learned that at least one URAC reviewer is now reading this standard more broadly, saying that, despite the fact that an applicant is describing its member and client appeals system thoroughly enough, its submission is insufficient, in that it does not explain how employees and the community (including "office neighbors, parking or grounds attendants") can file a complaint.

Let there be no mistake -- this is no complaint. I have nothing vested in a particular interpretation of a URAC standard. If URAC wants to expand the scope of this standard to include employees and community members, more power to it. I provide this here simply to alert our readers that their submission for this standard is likely to be insufficient if it includes only a description of its complaints and appeals system for consumers and clients.