URAC Accreditation Consulting

URAC Transitions of Care Designation

A structured add-on credential that demonstrates your organization's commitment to safe, coordinated patient handoffs — and the infrastructure to prevent the gaps that drive preventable readmissions.

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What Is the URAC Transitions of Care Designation?

The URAC Transitions of Care (TOC) Designation is a credential issued by the Utilization Review Accreditation Commission (URAC) to organizations that have demonstrated compliance with a defined set of standards governing the safe and timely transfer of patients from one care setting or level of care to another.

Unlike standalone URAC accreditations, the TOC Designation is an add-on credential — it is awarded in conjunction with an organization's existing URAC accreditation. It recognizes that care coordination breakdowns at transition points are among the most persistent drivers of adverse events, medication errors, and preventable readmissions in American healthcare.

Organizations that achieve the TOC Designation demonstrate to payers, network partners, and regulators that their patient handoff infrastructure is not informal — it is standards-based, documented, and validated by an independent third party.

One in five Medicare patients is readmitted within 30 days of discharge. Research estimates that up to 75% of those readmissions are preventable with structured transitions of care protocols. The TOC Designation exists to close that gap.

Which Organizations Are Eligible?

The URAC TOC Designation is available to organizations that already hold — or are actively pursuing — an applicable URAC accreditation. Eligible program types include:

Health Plans — commercial, Medicaid managed care, Medicare Advantage, and Marketplace health plans
Case Management Organizations — standalone or embedded case management programs pursuing or holding URAC Case Management accreditation
Clinically Integrated Networks (CINs) — multi-provider networks coordinating care across settings
Telehealth Providers — organizations providing remote clinical services where care transitions span virtual and in-person settings
Home Infusion Therapy Services — programs discharging patients to home-based infusion therapy from acute or post-acute settings
Patient-Centered Medical Home (PCMH) Organizations — at any level of URAC PCMH certification

The TOC Designation is not a standalone program. Organizations must hold or be pursuing a qualifying URAC accreditation as the primary credential. IHS can advise on sequencing if the base accreditation and TOC Designation are being pursued simultaneously.

What the Standards Cover

URAC's TOC standards are organized around the five core functions that define a structurally sound transitions of care program. Each standard requires documented policies, operational evidence, and — where applicable — data demonstrating consistent execution over a look-back period.

1. Risk Identification

Identifying patients at elevated risk for poor transitions before the transition occurs. Standards address screening criteria, clinical triggers, and integration with existing case management or utilization management workflows.

2. Comprehensive Transition Assessment

Conducting a structured assessment at transition that captures medical, behavioral, social, and functional factors affecting the patient's ability to navigate the new care setting. Assessment documentation must meet defined content and timeliness standards.

3. Medication Reconciliation

Performing and formally communicating a medication reconciliation at each transition point. Standards address accountability (which clinician is responsible), documentation requirements, and communication to receiving providers. Clinical pharmacist involvement is recognized as a quality-enhancing component.

4. Dynamic Care Management Plan

Establishing a care plan that spans the full continuum — not just the acute episode — and is updated as the patient's status and setting change. Standards address plan content, patient and caregiver involvement, and cross-setting coordination.

5. Transition Information Communication

Communicating essential transition information to all key stakeholders — receiving providers, the patient, family caregivers, and the payer — within defined timeframes. Standards address content requirements, format, and documentation of receipt.

The complete URAC TOC standards document is available for purchase through the URAC store. IHS works from the primary standards text — not summaries — throughout every engagement.

Why Organizations Pursue the TOC Designation

Contractual and Network Requirements

Health plans are increasingly requiring downstream providers — case management vendors, CINs, home health agencies — to demonstrate structured transitions of care capabilities. The TOC Designation provides a defensible third-party validation of those capabilities.

Value-Based Contract Performance

Organizations participating in value-based arrangements — ACOs, bundled payments, shared savings programs — face financial consequences for preventable readmissions. The TOC Designation represents the infrastructure that makes readmission reduction measurable and sustainable.

CMS Quality Reporting

Medicare Advantage plans and Medicaid managed care organizations face increasing CMS scrutiny over care transition performance. The TOC Designation aligns organizational practices with federal quality expectations and provides documentation infrastructure for audits.

Differentiation in a Crowded Market

When RFPs ask for evidence of structured care coordination, the TOC Designation provides an answer that a policy binder cannot. It signals that an external body reviewed your operations and confirmed compliance — not just that you wrote a protocol.

Internal Program Improvement

Many organizations pursue the designation because the standards provide an authoritative framework for building or rebuilding a transitions of care program. The process of preparing for URAC review surfaces operational gaps that internal assessments routinely miss.

How IHS Supports the TOC Designation Process

IHS brings a perspective on URAC standards that no other consulting firm can replicate. Thomas G. Goddard, JD, PhD — IHS's principal consultant — served as former Chief Operating Officer and General Counsel of URAC. He has read every version of every URAC standard from inside the organization that wrote them.

That insider knowledge shapes how IHS approaches every TOC engagement:

Standards Acquisition and Orientation

IHS guides clients through purchasing the correct version of the TOC standards from the URAC store and orients leadership to what the standards require in operational terms — not in the abstract language of the standards document itself.

Gap Analysis Against Current Operations

A structured Standard-by-Standard Review maps your current policies, procedures, technology, and workflows against each TOC standard. The output is a prioritized gap list — not a general readiness score — with specific remediation assignments.

Policy and Procedure Development

Where gaps exist in written documentation, IHS develops or revises policies and procedures that reflect both URAC's language requirements and your organization's actual operational model. Policies written to sound compliant without being operationally grounded fail at survey.

Look-Back Period Strategy

URAC evaluates longitudinal adherence, not point-in-time compliance. IHS structures the implementation timeline so that look-back period evidence accumulates before the survey window — not after the application is filed.

Medication Reconciliation Infrastructure

Given the specificity of URAC's medication reconciliation standards — including accountability assignment, documentation format, and communication requirements — IHS provides dedicated support for building or remediating this component, which is among the most commonly deficient at survey.

Mock Survey and Validation

IHS conducts a pre-submission mock survey that replicates URAC's review process. Gaps identified in mock survey are remediable. Gaps identified during the actual URAC review become RFIs — which extend the timeline and increase organizational stress.

AccreditNet Submission Support

IHS supports the full AccreditNet submission process, including document organization, evidence labeling, and reviewer-facing narrative where required. A well-organized submission reduces the likelihood of RFIs from ambiguity alone.

RFI Response

When URAC issues Requests for Information (RFIs) during review, IHS prepares responses that directly address the reviewer's stated deficiency — without scope creep, without conceding non-issues, and within URAC's response window.

Common Challenges in TOC Designation Preparation

Organizations that attempt the TOC Designation without experienced guidance consistently encounter the same failure patterns. IHS has observed these across client engagements and URAC's own published data:

Treating the TOC as a paperwork exercise. URAC reviewers look for evidence that processes are actually operating — not just documented. Organizations that write policies without building operational workflows fail on the evidence requirement.
Medication reconciliation accountability gaps. URAC's standards are specific about which clinician is accountable for the reconciliation. Organizations that treat this as a shared or informal responsibility cannot satisfy the standard.
Inadequate look-back period planning. Organizations that implement TOC processes close to the survey date cannot produce the longitudinal evidence URAC requires. The look-back period must be built into the implementation timeline from the start.
Communication documentation failures. Standard 5 (transition information communication) requires documented evidence that the right information reached the right stakeholders within the required timeframe. Informal communications do not satisfy this standard.
Siloed implementation. The TOC standards span clinical operations, care management, pharmacy, IT, and member services. Organizations that assign the project to one department without cross-functional accountability produce gaps at every handoff between departments — the precise failure the standards are designed to prevent.
Base accreditation misalignment. Because the TOC Designation layers atop an existing accreditation, changes to the base accreditation program can create compliance conflicts. IHS monitors both tracks throughout the engagement.

Start with a Discovery Session

The TOC Designation process starts with understanding where your organization currently stands — relative to URAC's standards, relative to your base accreditation timeline, and relative to the operational infrastructure you already have in place. A free discovery session with IHS establishes that baseline and gives you a clear view of what the path forward requires.

Thomas G. Goddard, JD, PhD — former Chief Operating Officer and General Counsel of URAC — leads every IHS engagement personally.