URAC Case Management and Utilization Management Accreditation Consulting
Last updated: October 2026
URAC Case Management accreditation and URAC Health Utilization Management (HUM) accreditation are 3-year URAC credentials for organizations that coordinate patient care or review and authorize medical services, and Integral Healthcare Solutions (IHS) prepares organizations for both, working to Case Management v7.0 and Health Utilization Management v8.2.
The programs are for managed care organizations, third-party administrators, health systems, independent review organizations and behavioral health entities. URAC governs them and makes every accreditation decision. IHS, founded in 2002 by Thomas G. Goddard, JD, PhD, former Chief Operating Officer and General Counsel of URAC, takes you from Standard-by-Standard Review and look-back planning through the Mock Desktop Review and validation review support. IHS drafts the policies and program content for your clinicians to review and approve. Your organization's named contact submits to URAC.
What is URAC Case Management accreditation?
URAC Case Management accreditation is a 3-year credential for organizations that coordinate care for individual patients. The standards version IHS works to is Case Management v7.0. It covers how a case management program is structured, how members are screened and assessed, how care plans are built and monitored, and how cases are closed.
Assessments need to cover both physical and behavioral health, and medication review is part of the assessment. The standards use MM 2-2 for standardized assessment tools and MM 2-3 for medication assessment.
What is URAC Utilization Management (HUM) accreditation?
URAC Health Utilization Management (HUM) accreditation is a 3-year credential for organizations that review and authorize medical services. The version IHS works to is HUM v8.2. Its standards sit in five functional categories: Risk Management, Operations and Infrastructure, Performance Monitoring and Improvement, Consumer Protection and Empowerment, and Utilization Management.
The Utilization Management category covers clinical review criteria (UM 2-1), peer-to-peer conversations between treating physicians and plan reviewers (UM 11-1), notification timeframes (UM 12-1), appeals (UM 13, 14 and 16) and governance of AI and machine learning software used in review (UM 7-1).
Prior authorization is under close public attention. KFF reports that Medicare Advantage insurers made 52.8 million prior authorization determinations in 2024 (KFF, Medicare Advantage prior authorization determinations in 2024).
Who needs URAC case management and utilization management accreditation?
An organization needs it when a payer contract, a delegation agreement, a state rule or a customer names URAC for the work it does. The groups that pursue it include:
- Managed care organizations that need HUM for payer contracting or state requirements.
- Third-party administrators that run utilization management or care coordination for payers.
- Health systems with employed case management programs.
- Workers' compensation payers and employers, who may need URAC's separate Workers' Compensation UM program.
- Disability and specialty case management firms.
- Independent review organizations, which should also read our IRO accreditation page.
- Behavioral health organizations that manage substance use and mental health cases.
State requirements differ, so check the rule in each state where you operate. IHS reads your contracts and the state rule you give us, and plans the program around what they name.
What do the standards ask for, and where do organizations need to prepare?
IHS's Standard-by-Standard Review checks your documentation against each area below before submission. This is IHS's own review list, organized by the standard labels. The URAC standards govern what is required.
Case Management review areas
- Assessment and medication review (MM 2-2, MM 2-3). IHS builds assessment templates that cover physical and behavioral health with a medication review checklist.
- Case closure and refusal tracking (MM 4-1). IHS builds a way to record why members decline services and to sort the reasons for quality improvement.
- Assessment data sources. IHS documents where assessment data comes from and how each source is checked.
Utilization Management review areas
- Clinical review criteria (UM 2-1). IHS audits consistency across reviewers and builds training for whichever criteria set you use, such as InterQual or MCG.
- Peer-to-peer conversations (UM 11-1). IHS builds scheduling protocols with documented availability and backup reviewers.
- Notification timeframes (UM 12-1). IHS maps each notice type to its timeframe and builds escalation steps for edge cases.
- AI and machine learning software governance (UM 7-1). If you use automated prior authorization tools or AI-assisted review, IHS documents how the tools are selected and monitored.
Review areas across both programs
- Look-back evidence (OPIN 1-2). IHS plans for documented monitoring over time from the first month, because procedures adopted shortly before a review show little history.
- Complaint response timeliness (CPE 2-3). IHS builds complaint tracking templates with escalation triggers tied to your own internal deadlines.
- Plain-language consumer communications (CPE 2-4). IHS rewrites determination letters, care plans and denial notices in plain language.
- Security risk assessment (RM 3-2). IHS coordinates a documented risk assessment that addresses protected health information.
- Clinical staff verification (OPIN 2-1). IHS builds tracking templates with a verification schedule for licenses.
How does the URAC case management and utilization management process work?
The IHS planning range is 10 to 14 months from kickoff to a final determination, in six steps. That is IHS's estimate and not a URAC figure. The look-back period makes it longer than programs that need no operating history, so start early.
Step 1: Standard-by-Standard Review (months 1-2)
IHS trains your staff on each applicable CM v7.0 and HUM v8.2 standard and explains what reviewers look for in the desktop review. IHS sets the look-back plan at this step, because it cannot be backfilled later.
Step 2: Document preparation (months 3-6)
IHS drafts policy templates for the applicable standard modules. Your subject matter experts adapt them to your operations, and IHS assists as needed. Your organization starts operating under the new procedures right away so the look-back record builds.
Step 3: Mock Desktop Review (month 7)
IHS reviews your documents in Starfinch against the governing standards and gives feedback before you submit to URAC. The review looks for remaining gaps.
Step 4: URAC application and document submission (month 8)
URAC uses the word application for two things. The first is a short opening form, after which URAC generates a contract that you sign and pay. The second is the document submission through AccreditNet, which URAC gives you a deadline for. Your organization's named contact handles both. IHS drafts the documents and does not submit them.
Step 5: Desktop review and RFIs (months 9-13)
URAC's desktop review produces feedback as a Request for Information (RFI). IHS drafts RFI responses for your named contact to submit and supports your team through the validation review, which URAC may run virtually or on-site.
Step 6: Determination (month 14)
URAC makes the determination. Accreditation lasts 3 years.
What internal staffing does it take?
- Executive sponsor (for example a CMO or VP of Quality) who secures buy-in and budget and signs attestations.
- Project lead who owns the timeline and document control and is IHS's day-to-day contact.
- Clinical subject matter experts such as medical directors and nurse reviewers, for clinical criteria and peer-review protocols.
- IT and compliance staff for information systems, risk assessment and business continuity documentation.
What does URAC case management and utilization management accreditation cost?
The cost has three parts: URAC's fee, consulting fees and your internal staff time. URAC does not publish its fees. Each applicant gets its fee in its URAC contract and pays it at signing, so your named contact gets the figure from URAC.
IHS sets a fixed fee for each engagement after a free discovery session, because scope, number of sites and gap severity change the work. For the internal staffing side of the budget, see the CM/UM Accreditation Cost Guide.
What this is not
- IHS is not an accrediting body and does not grant or influence a URAC decision.
- IHS drafts. Your organization's named contact handles every submission and all communication with URAC.
- This page is not legal advice about state utilization review requirements.
- Preparation is not a guarantee of an accreditation outcome.
How does IHS help with URAC case management and utilization management accreditation?
The IHS process covers standards acquisition, Standard-by-Standard Review, gap assessment, document and evidence mapping, Mock Desktop Review and readiness support. Since 2002, IHS has guided healthcare organizations through accreditation. Thomas G. Goddard, JD, PhD, personally leads IHS's URAC and program-development engagements.
- Look-back planning from day one. Procedures adopted just before a review leave little history for reviewers to see.
- Mock review work. IHS runs reviews with staff interviews, case file reviews and scored standard evaluations. More than one mock review gives staff repeat practice before the real one.
- Prior authorization readiness. IHS designs UM documentation to hold up as requirements change.
If you are comparing URAC and NCQA for case management, see the URAC vs NCQA Case Management Accreditation comparison. NCQA accreditation work at IHS is led by Maureen Plumstead. See also NCQA Case Management, URAC Health Plan Accreditation and the Accreditation Consulting hub.
Frequently asked questions
What is the difference between URAC case management and utilization management accreditation?
Case Management covers coordination of care for individual patients: screening, assessment, care plans, monitoring and closure. Utilization Management covers review and authorization of medical services: clinical criteria, prior authorization, peer-to-peer conversations, notification and appeals. Many organizations need both.
How long does URAC CM/UM accreditation take?
The IHS planning range is 10 to 14 months from kickoff to determination. That is IHS's estimate, not a URAC figure. The look-back period is the main reason it runs long.
What is a look-back period and why does it matter?
It is the history showing that your procedures have been followed over time. Reviewers look for evidence of ongoing practice, so procedures started days before a review show little. IHS builds the look-back plan from the first month of an engagement.
Does URAC have workers' compensation UM accreditation?
Yes. URAC has a Workers' Compensation UM program that is separate from Health UM. Choose the one that matches your operations. See URAC Workers' Compensation UM.
Do independent review organizations need URAC accreditation?
That depends on the state rules and customer contracts that apply to you. IROs have their own URAC program, covered on the URAC IRO accreditation page.
Which assessment tools should we use for case management?
The standards ask for standardized tools for assessment, re-assessment and the plan of care (MM 2-2). IHS maps the tools you already use to those standards and recommends changes based on your organization and member population.
Does IHS help with performance measure reporting?
IHS helps you build data extraction and reporting routines so that any measure your organization reports comes from systems you already run. Confirm which measures apply to you against your URAC contract.
Who is this not for?
It is not for an organization that wants IHS to apply to URAC for it or speak to URAC on its behalf. Your named contact does that. It is also not for an organization whose contracts and state rules name no accreditation and that has no plan to pursue one.
Ready to prepare for URAC case management or utilization management accreditation?
Start with a free discovery session. IHS will review your current documentation against URAC CM v7.0 and HUM v8.2 and outline a plan that includes look-back planning from day one.