URAC P-CR 3 and N-CR 3 -- Credentialing Committee

CR 3, describing the structure and responsibilities of the Credentialing Committee, reads:

The organization establishes a credentialing committee that: (Primary)
    (a) Includes at least one participating provider who is a practitioner and who has no other role in organization management; (Primary)
    (b) Discusses whether providers are meeting reasonable standards of care; (Primary)
    (c) Accesses appropriate clinical peer input when discussing standards of care for a particular type of provider; (Secondary)
    (d) Has final authority to: (Primary)
        (i) Approve or disapprove applications by providers for organization participation status; or (Primary)
        (ii) Delegate such authority to the senior clinical staff person for approving clean applications, provided that such designation is documented and provides reasonable guidelines; (Primary)
    (e) Maintains minutes of all committee meetings and documents all actions; (Secondary)
    (f) Provides guidance to organization staff on the overall direction of the credentialing program; (Secondary)
    (g) Evaluates and reports to organization management on the effectiveness of the credentialing program; (Secondary)
    (h) Reviews and approves credentialing policies and procedures; and (Secondary)
    (i) Meets as often as necessary to fulfill its responsibilities, but no less than quarterly. (Secondary)

The standard carries a weight of "4", and has a number of primary elements, so it's fairly easy to lose a significant number of points if your documentation is not up to par.  For purposes of the application at the AccreditNet submission stage, URAC recommends a detailed organization chart of the entire credentialing program, including the committee, as well as formal credentialing plan and P&Ps.  In addition, meeting minutes from the Credentialing Committee are essential to demonstrate that the plan and P&Ps are being implemented.

In recent reviews, URAC reviewers have been known to "ding" an application that doesn't provide enough detail about the participating providers on the committee.  URAC has said that it wants, specifically, "a description of the participating provider(s) member(s) and the requirements, terms, duration, selection procedures of their committee responsibilities."

Another recently noted stumbling block has been around subsection (d)(ii).  Even where your P&Ps note that the committee has the authority to delegation the handling of "clean claims" to the medical director, if your documentation does not actually indicate that it has (or has not) so delegated, you're likely to get the following comment back from the reviewer:

"Clarify whether or not the committee delegates approval of clean applications to the senior medical director."

URAC is likely to accept a variety of types of documentation to demonstrate this, either in the form of a P&P, committee charter, or committee minutes showing the act of delegation.