URAC Case Management and Utilization Management Accreditation FAQ — Your Questions Answered

Last updated: October 2026

Everything you need to know about URAC Case Management v7.0 and Health Utilization Management v8.2 accreditation — from standards requirements and look-back periods to deficiencies, cost, and workers' compensation UM. Answers from IHS, a specialized healthcare accreditation consulting firm led by Thomas G. Goddard, JD, PhD, former Chief Operating Officer and General Counsel of URAC.

What Is URAC Case Management Accreditation?

URAC Case Management Accreditation is a three-year quality credential from the Utilization Review Accreditation Commission recognizing organizations that meet 51 standards for coordinating patient care under Case Management v7.0, implemented in 2022. The standards span the full case management lifecycle: program structure (MM 1-1), screening processes (MM 2-1), comprehensive assessments including both physical and behavioral health perspectives and medication review (MM 2-2, MM 2-3), individualized member care plans (MM 3-1), monitoring of progress (MM 3-2), and formal case closure criteria with documented discharge requirements (MM 4-1).

For a full overview, see our CM/UM Accreditation service page.

What Is URAC Utilization Management (HUM) Accreditation?

URAC Health Utilization Management (HUM) Accreditation is a three-year credential covering 30 standard slots (27 actively scored) across 5 functional categories. The current active version is HUM v8.2, a sequential iteration of v8.0 released in November 2021. HUM standards govern the review and authorization of medical services — evidence-based clinical review criteria (UM 2-1), AI/ML medical software governance (UM 7-1), peer-to-peer conversations (UM 11-1), notification timeframes (UM 12-1), and appeals processes (UM 13, 14, 16).

Medicare Advantage insurers made 52.8 million prior authorization determinations in 2024, and 4.1 million requests were fully or partially denied; most appeals of denials (80.7%) were partially or fully overturned, and only 11.5% of denials were appealed (<a href="https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/">KFF</a>).

What Is the Difference Between URAC Case Management and Utilization Management Accreditation?

Case Management and Utilization Management address different operational functions. Understanding the distinction determines which accreditation your organization needs.

Case Management (CM v7.0, 51 standards) covers coordination of care for individual patients across the continuum. CM standards address screening, assessment (physical, behavioral, medication), care plan development, progress monitoring, and case closure. CM is patient-centered and longitudinal.

Utilization Management (HUM v8.2, 30 standard slots) covers review and authorization of medical services. UM standards address medical necessity determination, clinical review criteria application, prior authorization, peer-to-peer conversations, notification, and appeals. UM is service-centered and transactional.

Some organizations, such as MCOs, integrated health systems, and TPAs, operate both functions and pursue dual accreditation. IHS manages dual CM/UM engagements with coordinated timelines and shared documentation where standards overlap.

Who Needs URAC Case Management Accreditation?

Seven categories of organizations pursue URAC CM accreditation:

• Managed Care Organizations (MCOs): Health plans operating care coordination programs, sometimes required for state Medicaid contracting
• Third-Party Administrators (TPAs): Commercial payers outsourcing care coordination for self-insured employer clients
• Integrated Health Systems: Hospital networks with employed CM teams managing chronic disease populations
• Workers' Compensation Organizations: Using URAC Workers' Compensation CM modules for return-to-work validation
• Specialized Disability Management Firms: Catastrophic care managers, dialysis networks, oncology coordinators, transplant managers
• Independent Review Organizations (IROs): External review entities needing URAC accreditation for state regulatory recognition
• Behavioral Health Organizations: Entities managing SUD and mental health CM with MHPAEA compliance requirements

URAC fulfills state requirements in 13 states: CT, FL, IA, MI, MN, MT, ND, NJ, NM, NV, TX, UT, VT.

How Long Does URAC Case Management Accreditation Take?

10 to 14 months from consulting engagement to formal accreditation. IHS plans for that range because of the look-back period requirement.

The timeline breaks down across six phases:

1. Discovery and Standard-by-Standard Review (Months 1-2) — audit against 51 CM or 30 HUM standard slots; Readiness Roadmap with look-back strategy
2. Policy Development and Process Engineering (Months 3-6) — drafting documentation, implementing procedures, building look-back data
3. Mock Survey (Month 7) — simulated validation reviews
4. AccreditNet Submission (Month 8) — formal application with complete documentation upload
5. URAC Review and Validation (Months 9-13) — desk review, RFIs, validation review with staff interviews
6. Final Determination (Month 14) — accreditation committee decision

How Much Does URAC CM or UM Accreditation Cost?

URAC fees are customized based on organizational size, number of operational sites, and modules selected. URAC does not publicly disclose its fee schedules. Contact URAC directly for current pricing.

• URAC direct fees: Application deposit (credited toward final fee), primary accreditation fee, annual maintenance fees. Non-refundable if denied.
• IHS consulting fees: Engagements are scoped to each client's specific situation. IHS begins every engagement with a complimentary discovery call that produces a fixed-fee proposal tailored to your organization's size, documentation maturity, and timeline. Contact us to schedule.
• Internal staffing: Executive sponsor, project lead, clinical SMEs, IT/compliance across 10-14 months

For complete cost breakdown, see our CM/UM Accreditation Cost Guide.

What Is the Current Version of URAC Case Management Standards?

Case Management v7.0, copyrighted and implemented in 2022. V7.0 encompasses 51 standards across categories including Management of Members (MM), Quality and Training Requirements (QTR), Reporting Performance Measures (RPT), and shared core categories.

What Changed in URAC Case Management v7.0 vs v6.0?

V7.0 introduced changes that affect preparation. Key changes:

• Standardized assessment tools (MM 2-2): Now mandated for assessment, re-assessment, and plan of care
• Documented case closure criteria (MM 4-1): Formal criteria with structured refusal tracking.
• Assessment data source identification: Must specify where data originates and how sources are validated
• Enhanced behavioral health integration: Assessments must include physical and behavioral health perspectives
• Medication assessment (MM 2-3): Comprehensive medication review became a formal assessment component

Which Areas Can Lead to Findings in URAC CM Accreditation?

Areas that can lead to findings include:

1. Assessment documentation (MM 2-2): Incomplete physical and behavioral health assessments; failure to use standardized tools
2. Medication assessment (MM 2-3): Incomplete medication reconciliation; missing adherence documentation
3. Look-back period failures (OPIN 1-2): Insufficient longitudinal evidence of procedure adherence
4. Complaint response timeliness (CPE 2-3): Complaints not resolved within the organization's specified timeframes
5. Consumer communication jargon (CPE 2-4): Clinical terminology in patient-facing documents
6. Case closure refusal tracking (MM 4-1): Failure to categorize why patients decline services
7. Lapsed clinical staff verifications (OPIN 2-1): Expired primary source verification
8. Performance measure reporting (PMI 2-1): Inability to extract required annual measures
9. Quality meeting minutes (PMI 1-1): Missing QMC documentation with corrective action tracking
10. Security audit gaps (RM 3-2): Generalized IT policies rather than PHI-specific risk assessments

What Standardized Tools Are Required for URAC Case Management?

CM v7.0 requires standardized tools for assessment, re-assessment, and plan of care (MM 2-2), but the standards deliberately do not specify which instruments. "Standardized" means validated, consistently applied, and reproducible instruments — not unstructured clinical notes or ad hoc judgment. The choice depends on organizational type and patient population. IHS provides guidance on which instruments satisfy this requirement.

What Is a Look-Back Period and Why Does It Matter?

The look-back period is URAC's requirement that organizations demonstrate longitudinal adherence to procedures — not just implement policies before the survey. It is why IHS plans for 10-14 months.

URAC surveyors review historical documentation spanning months: delegation oversight records, complaint response logs, quality meeting minutes, and clinical workflow documentation across many patient encounters. Policies implemented weeks before the survey cannot show that history. IHS establishes look-back strategy from day one of every engagement.

URAC vs NCQA Case Management: Which Should I Choose?

Key structural differences between URAC CM (v7.0, 51 standards) and NCQA CM:

NCQA accreditation and recognition engagements are led by Maureen Plumstead.

• Pre-condition: NCQA requires 6 months of CM service delivery before applying. URAC has no pre-condition.
• State recognition: URAC fulfills requirements in 13 states.
• Standards focus: URAC emphasizes operational compliance. NCQA emphasizes clinical quality measurement.

For full comparison, see our URAC vs NCQA Case Management comparison.

Do IROs Need URAC Accreditation?

Some states require Independent Review Organizations to hold URAC accreditation for regulatory recognition. IROs conduct external reviews of UM decisions when internal appeals are exhausted. URAC HUM accreditation demonstrates rigorous clinical review criteria application and appropriate reviewer qualifications. IHS provides targeted consulting for IROs.

Does URAC Have Workers' Comp UM Accreditation?

Yes. URAC offers a separate Workers' Compensation UM Accreditation distinct from Health UM (HUM). Illinois Workers' Compensation Act explicitly references URAC Workers' Comp UM Standards. The decision between health UM and workers' comp UM depends on your primary operational focus. Large TPAs serving both markets may need both.

What Performance Measures Does URAC Require?

URAC requires annual performance measure reporting throughout the 3-year cycle. Key CM measures:

• 30-day readmission rates
• Consumer complaint resolution: response time and on-time resolution
• Case closure tracking: Categorization of closure reasons, including member declination
• Patient outcome measures: Tracked from screening through closure

Organizations must build data systems to extract and report these measures. IHS designs measurement frameworks during Standard-by-Standard Review.

What Is the Behavioral Health Assessment Requirement?

CM v7.0 requires comprehensive assessments to include both physical and behavioral health perspectives — mental health status, substance use screening, psychosocial factors, and behavioral health needs regardless of primary enrollment reason. IHS builds integrated assessment templates covering both domains.

What Is the Medication Assessment Requirement?

CM v7.0 added comprehensive medication review as a formal assessment component (MM 2-3). Assessments must include complete medication reconciliation — all medications (prescription, OTC, supplements), dosages, prescribers, adherence patterns, and interactions. IHS builds medication review checklists integrated into the assessment workflow.

Ready to Get Started?

Schedule a no-obligation Standard-by-Standard Review with IHS. We will assess your current compliance posture against URAC CM v7.0 and HUM v8.2 standards and give you a clear roadmap to accreditation — including look-back period strategy from day one.

Schedule a Free Discovery Session