Frequently Asked Questions

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 structured set of standards governing the safe and timely transfer of patients between care settings or levels of care.

It is an add-on designation — layered on top of an existing URAC accreditation — that signals to payers, network partners, and regulators that an organization's patient handoff infrastructure is documented, operational, and independently validated.

No. The TOC Designation is not a standalone accreditation. It is awarded in conjunction with an existing URAC accreditation. Eligible base accreditations include:

• URAC Health Plan
• URAC Case Management
• URAC Clinically Integrated Network
• URAC Telehealth
• URAC Home Infusion Therapy Services
• URAC Patient-Centered Medical Home (any certification level)

Organizations must hold or be actively pursuing one of these base credentials to be eligible for the TOC Designation.

Organizations that manage patients across care settings or levels of care are the primary candidates. This includes:

• Health plans — commercial, Medicare Advantage, Medicaid managed care, Marketplace
• Case management organizations
• Clinically integrated networks
• Telehealth providers
• Home infusion therapy programs
• Patient-Centered Medical Home organizations

The designation is also relevant for organizations participating in value-based contracts — ACOs, bundled payment arrangements, shared savings programs — where preventable readmissions carry direct financial consequences.

URAC's TOC standards address five core functions:

1. Risk Identification — Identifying patients at elevated risk for poor transitions before the transition occurs, using defined screening criteria and clinical triggers.
2. Comprehensive Transition Assessment — Conducting a structured assessment that captures medical, behavioral, social, and functional factors affecting the patient's ability to navigate the new care setting.
3. Medication Reconciliation — Performing and formally communicating a medication reconciliation at each transition point, with documented accountability for which clinician is responsible.
4. Dynamic Care Management Plan — Establishing a care plan that spans the full continuum and is updated as the patient's situation and setting change.
5. Transition Information Communication — Communicating essential transition information to all key stakeholders — receiving providers, the patient, caregivers, and the payer — within defined timeframes.

Transitions of care refers to the movement of a patient from one care setting to another — for example, from an acute hospital to a skilled nursing facility, from inpatient to home health, from an emergency department to primary care follow-up, or from one level of behavioral health treatment to another. It also encompasses transitions between levels of care within a single setting.

URAC's TOC standards address the structural and communication failures that occur at these handoff points — failures that research consistently links to adverse events, medication errors, and preventable readmissions. 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 transition protocols.

URAC Case Management accreditation is a standalone credential covering the full lifecycle of a case management program — screening, assessment, care planning, monitoring, and case closure — across all types of cases. The TOC Designation is narrower and specifically focused on the transition points between care settings.

An organization can hold Case Management accreditation without the TOC Designation. The TOC Designation functions as a complement — demonstrating that the organization's transition-specific protocols meet an additional layer of rigor beyond what the base Case Management credential requires.

Medication discrepancies at transition points are among the most common sources of patient harm in the U.S. healthcare system. When a patient moves from an acute setting to home or post-acute care, the receiving care team may have incomplete, outdated, or conflicting medication information.

URAC's TOC standards address this directly — requiring not just that a reconciliation occur, but that accountability for the reconciliation be formally assigned, that the process be documented, and that the reconciled medication list be communicated to the receiving provider and the patient within specified timeframes. Clinical pharmacist involvement is recognized by URAC as a quality-enhancing element of this process.

URAC evaluates TOC Designation compliance through a document review process submitted via AccreditNet — URAC's online accreditation portal. Reviewers examine:

• Written policies and procedures
• Operational documentation demonstrating process execution
• Case-level evidence demonstrating consistent application over a look-back period

URAC does not rely solely on policy documents. Where submitted evidence is insufficient or ambiguous, URAC issues a Request for Information (RFI), which extends the review timeline.

A look-back period is the span of time over which URAC evaluates whether an organization's documented processes have actually been followed in practice. URAC does not grant a designation based on policies written immediately before the survey — it requires evidence of longitudinal adherence.

For the TOC Designation, this means organizations must have their transition protocols operational and generating documentation for a meaningful period before the survey window. Organizations that implement processes too close to their application date cannot produce sufficient look-back period evidence and risk delays or denial.

URAC fees are customized based on organizational size, program scope, and the structure of the base accreditation engagement. URAC does not publish a standard fee schedule, and fees are non-refundable if the designation is not awarded. Contact URAC directly to discuss fee structure for your specific situation.

IHS consulting engagements are scoped to each client's specific situation — contact IHS for a tailored proposal.

The timeline depends on the organization's starting point — specifically, how mature its existing transitions of care infrastructure is and how well its base accreditation programs are performing. Organizations with established care coordination programs that already execute many TOC-aligned functions may move more quickly than organizations building from scratch.

IHS structures engagement timelines to account for look-back period requirements — the operational readiness phase must precede the survey window by a meaningful interval. A realistic planning horizon is generally six to twelve months from engagement start to survey submission.

Yes, with careful sequencing. URAC permits organizations pursuing an initial base accreditation to simultaneously pursue the TOC Designation. However, this approach requires precise timeline management — the look-back period requirements for both credentials must be satisfied concurrently, and changes made to satisfy base accreditation standards must not inadvertently create gaps in TOC Designation compliance.

IHS manages both tracks simultaneously when organizations choose this approach.

A Request for Information (RFI) is issued when a URAC reviewer determines that submitted evidence does not fully satisfy a standard. The organization has a defined window to respond with additional documentation or clarification. RFIs extend the review timeline and, if not responded to effectively, can result in conditional designation or denial.

IHS prepares RFI responses that directly address the reviewer's stated deficiency — without scope creep, without conceding non-issues, and within URAC's response window. Organizations that attempt RFI responses without experienced guidance frequently over-respond, under-respond, or inadvertently open new review issues.

The most consistent failure pattern is the gap between written policy and operational evidence. Organizations that write compliant-sounding policies but have not built the workflows, documentation practices, and accountability structures to execute those policies consistently cannot satisfy URAC's evidence requirements.

Medication reconciliation accountability gaps and communication documentation failures are the two most frequently cited deficiencies. A secondary failure driver is insufficient look-back period evidence — organizations that implement TOC processes too close to the survey date cannot demonstrate the longitudinal adherence URAC requires.

Thomas G. Goddard, JD, PhD — IHS's principal consultant — served as the former Chief Operating Officer and General Counsel of URAC. He helped develop and interpret the standards that URAC reviewers apply. That insider perspective means IHS reads every standard the way a URAC reviewer reads it — not the way a compliance checklist does.

IHS does not outsource engagement work to junior consultants. Every engagement is led personally by Thomas G. Goddard, applying 25+ years of URAC-specific expertise to the specific operational realities of each client.