Docket: CMS-2009-0040 

Request for Information Regarding the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008 

Comment On: CMS-2009-0040-0001 

Request for Information Regarding the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008 

Document: CMS-2009-0040-DRAFT-0021 

DC 

Submitter Information 

Name: Mara Osman 

Address: 

Washington, DC, 20005 

Organization: URAC 

General Comment 

URAC is pleased to submit its comments in response to your Request for 

Information Regarding the Paul Wellstone and Pete Domenici Mental Health Parity 

and Addiction Equity Act of 2008 (MHPAEA), as published in the Federal Register 

on April 28, 2009. 

As a nationally recognized health care accreditation organization with wide 

ranging expertise which includes leadership in accrediting behavioral health 

networks, as well as utilization review and worker’s compensation programs, our 

standards help organizations achieve a high bar on the quality of services 

rendered to their beneficiaries. 

In response to the Departments’ request for industry feedback on the six 

specific areas identified in the Federal Register notice, URAC is pleased to 

respond to items 3, 4, and 5 as cited in the attached comments, providing the 

relevant URAC accreditation standards as requested. 

PUBLIC 

SUBMISSION 

As of: May 28, 2009 

Received: May 27, 2009 

Status: Draft 

Category: Health Care Professional/Association - Other Health Care Professional

Tracking No. 809b9c10 

Comments Due: May 28, 2009 

Submission Type: Web
Attachments 

CMS-2009-0040-DRAFT-0021.1: DC

CMS-2009-0040-DRAFT-0021.2: DC
1220 L Street NW, Suite 400 ♦ Washington, D.C. 20005 ♦ Phone (202) 216-9010 ♦ Fax (202) 216-9006 ♦ www.urac.org 1

Promoting Quality Health Care 

Through Accreditation, Education & Measurement

May 27, 2009 

Ms. Charlene Frizzera 

Acting Administrator 

Centers for Medicaid & Medicaid Services 

Department of Health and Human Services 

Attention: CMS-4140-NC 

P.O. Box 8017 

Baltimore, MD 21244-8010 

Re: CMS-4140-NC; 42 CFR Parts 144 and 146 

Dear Acting Administrator Frizzera: 

URAC is pleased to submit its comments in response to your Request for Information Regarding 

the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 

(MHPAEA), as published in the Federal Register on April 28, 2009. 

As you may be aware, URAC was founded 19 years ago by representatives of provider groups, 

insurers, health care purchasers, consumers, and regulators to develop and enforce industry 

standards for proper utilization management of health care services. We accredit over 200 

purveyors of utilization management services across the country, including dozens who review 

the necessity of mental health services. Our utilization management programs are more widely 

recognized by governmental purchasers and regulators than any other managed care accrediting 

program in the United States. For more information about URAC and its governmental 

recognitions, please refer to appendix A of this letter. Also attached for your information are the 

Health Utilization Management Accreditation Standards, Version 6.0, in appendix B. 

As a nationally recognized health care accreditation organization with wide ranging expertise 

which includes leadership in accrediting behavioral health networks, as well as utilization review 

and worker’s compensation programs, our standards help organizations achieve a high bar on the 

quality of services rendered to their beneficiaries. 

In response to the Departments’ request for industry feedback on the six specific areas identified 

in the Federal Register notice, URAC is pleased to respond to items 3, 4, and 5 as cited below, 

providing the relevant URAC accreditation standards as requested. 

A. Request for Industry Standards Relating to Medical Necessity and Denial of Coverage 

“3. What information, if any, regarding the criteria for medical necessity determinations made 

under the plan (or coverage) with respect to mental health or substance use disorder benefits is 
1220 L Street NW, Suite 400 ♦ Washington, D.C. 20005 ♦ Phone (202) 216-9010 ♦ Fax (202) 216-9006 ♦ www.urac.org 2

currently made available by the plan? To whom is this information currently made available and 

how is it made available? Are there industry standards or best practices with respect to this 

information and communication of this information? 

4. What information, if any, regarding the reasons for any denial under the plan (or coverage) of 

reimbursement or payment for services with respect to mental health or substance use disorder 

benefits is currently made available by the plan? To whom is this information currently made 

available and how is it made available? Are there industry standards or best practices with

respect to this information and communication of this information?”

URAC Response: 

URAC’s Health Utilization Management Accreditation Standards, Version 6.0, contain 

detailed requirements for both oral discussion and written disclosure of the underlying clinical 

rationale for a decision to deny payment for a requested covered service to the patient, attending 

physician, or other ordering provider or facility. This denial is known as a Non-Certification 

decision. The relevant URAC standards, HUM 15, HUM 16, HUM 22, HUM 23, HUM 24, 

HUM 26, HUM 27, and HUM 28, related guidance for interpreting HUM 22 and HUM 23, and 

required content for notification letters, appeals, and written responses to requests for additional 

clarification of the clinical rational for non-certification, are provided below. The full set of 

URAC Health Utilization Management Accreditation Standards, Version 6.0, are provided in 

Appendix B. 

 HUM 15 – Peer-to-Peer Conversation Availability 

Health professionals that conduct peer clinical review are available to discuss review 

determinations with attending physicians or other ordering providers. 

 HUM 16 – Peer-to-Peer Conversation Alternate 

When a determination is made to issue a non-certification and no peer-to-peer conversation has 

occurred: 

(a) The organization provides, within one business day of a request by the attending physician or 

ordering provider, the opportunity to discuss the non-certification decision: 

(i) With the clinical peer reviewer making the initial determination; or 

(ii) With a different clinical peer, if the original clinical peer reviewer cannot be 

available within one business day); and 

(b) If a peer-to-peer conversation or review of additional information does not result in a 

certification, the organization informs 

 HUM 22 – Written Notice of Non-Certification Decisions and Rationale 
1220 L Street NW, Suite 400 ♦ Washington, D.C. 20005 ♦ Phone (202) 216-9010 ♦ Fax (202) 216-9006 ♦ www.urac.org 3

For non-certifications, the organization issues written notification of the non-certification 

decision to the patient and attending physician or other ordering provider or facility rendering 

service that includes: 

(a) The principle reasons for the determination not to certify; 

(b) A statement that the clinical rationale used in making the non-certification decision will be 

provided, in writing, upon request; and 

(c) Instructions for: 

(i) Initiating an appeal of the non-certification; and 

(ii) Requesting a clinical rationale for the non-certification. 

Interpretive Guidance:

• A principal reason statement that is non-specific, i.e., “care not found to be medically 

necessary” does not meet the intent of HUM 22(a). 

• Non-certification notification will be timely, will be provided in writing and will include 

the information needed to provide the basis for an appeal. 

• The health literacy /education level and linguistic needs of the population served should 

be considered when developing the non-certification letter templates to patients/members. 

• HUM 22a: The principal reason for the non-certification determination should include a 

general clinical or non-clinical statement as to why the UM organization said “no” to the 

request. For example, “care could be provided in a less acute setting,” “insufficient 

diagnostic work-up,” and “conservative treatment not tried nor ruled out,” etc. 

• HUM 22a: A general statement such as “care is not medically necessary” does not meet 

the intent of the principal reason requirement. 

• HUM 22b: if the organization provides the clinical rationale in the non certification 

notification letter then the offer for the clinical rationale in writing would not be required. 

Remember that the clinical rationale is the specific reason why services are not being 

authorized specific to the consumer. 

• HUM 22b: Some state regulatory requirements may require that the clinical rationale be 

provided in the letter. Reference the state regulatory requirements for all states in which 

the Utilization Management Organization conducts business. 

• HUM 22b: URAC recognizes in certain circumstances (e.g., a potentially suicidal 

patient), it may not be appropriate to send the clinical rationale directly to the patient. For 

these exceptions, URAC will allow the UM organization to send the rationale to the 

provider, and have the provider discuss the clinical rationale with the patient. Note that 

this exception applies to clinical rationale, not principal reason. The letter to the patient 

should refer him or her to the physician or other ordering provider. 
1220 L Street NW, Suite 400 ♦ Washington, D.C. 20005 ♦ Phone (202) 216-9010 ♦ Fax (202) 216-9006 ♦ www.urac.org 4

• HUM 22c: The non-certification letter must include the process to request an appeal and 

the clinical rationale (if not provided in the letter). Some states have specific appeal 

language requirements and it would be prudent to check with regulatory compliance for 

guidance. 

• In some organizations, such as HMO’s and PPOs, the patient may not be financially 

responsible for the non-certification of services, therefore, a written notification letter 

may not be required to be sent to the patient. 

• The clinical rationale provides additional clarification of the clinical basis for a noncertification decision, and specific reasons why the patient's symptoms did not meet the 

clinical review criteria. The principal reason for the non-certification determination 

should include a clinical or non-clinical statement as to why the Utilization Management 

Organization said "no" to the request. For example, "care could be provided in a less 

acute setting", "insufficient diagnostic work-up", and "conservative treatment not tried 

nor ruled out", etc. are examples of acceptable documentation. A general statement such 

as "care is not medically necessary" does not meet the intent of the principal reason 

requirement. The principal reason for the non-certification determination should include 

a specific clinical or non-clinical statement. 

 HUM 23 Clinical Rationale for Non-Certification Requirements 

Upon request from the patient, attending physician, or other ordering provider or facility 

rendering service, the organization provides specific clinical rationale upon which the noncertification was based. 

Interpretive Guidance:

• The clinical rationale provides additional clarification of the clinical basis for a noncertification decision, and specific reasons why the patient’s symptoms did not meet the 

criteria. 

• URAC recognizes in certain circumstances (e.g., a potentially suicidal patient), it may not 

be appropriate to send the clinical rationale directly to the patient. For these exceptions, 

URAC will allow the UM organization to send the rationale to the provider, and have the 

provider discuss the clinical rationale with the patient. Note that this exception applies to 

clinical rationale, not principal reason. The letter to the patient should refer him or her to 

the physician or other ordering provider. 

• Clinical rationale provides supporting documentation specific to the patient under review, 

for a non-certification decision. Simply referring to clinical criteria is not sufficient to 

meet the standard. 

• The organization can provide the clinical rationale in the non-certification letter, in which 

case this standard would not be applicable. The organization’s policy and/or written 

procedures should indicate that the rationale is provided. 

 HUM 24 – Reversal of Certification Determinations
1220 L Street NW, Suite 400 ♦ Washington, D.C. 20005 ♦ Phone (202) 216-9010 ♦ Fax (202) 216-9006 ♦ www.urac.org 5

The organization does not reverse a certification determination unless it receives new 

information that is relevant to the certification and that was not available at the time of the 

original certification. 

 HUM 26 – Scope of Review Information 

The organization, when conducting routine prospective review, concurrent review, or 

retrospective review: 

(a) Accepts information from any reasonably reliable source that will assist in the certification 

process; 

(b) Collects only the information necessary to certify the admission, procedure or treatment, 

length of stay, or frequency or duration of services. 

(c) Does not routinely require hospitals, physicians, and other providers to numerically code 

diagnoses or procedures to be considered for certification, but may request such codes, if 

available. 

(d) Does not routinely request copies of all medical records on all patients reviewed; 

(e) Requires only the section(s) of the medical record necessary in that specific case to certify 

medical necessity or appropriateness of the admission or extension of stay, frequency or duration 

of service, or length of anticipated inability to return to work; and 

(f) Administers a process to share all clinical and demographic information on individual patients 

among its various clinical and administrative departments that have a need to know, to avoid 

duplicate requests for information from enrollees or providers. 

 HUM 27 – Prospective and Concurrent Review Determinations 

For prospective review and concurrent review, the organization bases review determinations 

solely on the medical information obtained by the organization at the time of the review 

determination. 

 HUM 28 – Retrospective Review Determinations 

For retrospective review, the organization bases review determinations solely on the medical 

information available to the attending physician or ordering provider at the time the medical care 

was provided. 

B. Request for Information on the Scope of Out-of-Network Coverage 

“5. To gather more information on the scope of out-of-network coverage, the Departments are 

interested in finding out whether plans currently provide out-of-network coverage for mental 
1220 L Street NW, Suite 400 ♦ Washington, D.C. 20005 ♦ Phone (202) 216-9010 ♦ Fax (202) 216-9006 ♦ www.urac.org 6

health and substance use disorder benefits. If so, how is such coverage the same as or different 

than out-of-network coverage provided for medical and surgical benefits?” 

URAC Response: 

URAC’s Health Plan Accreditation Standards, Version 6.0, contains a standard, provided 

below, P-NM 4, which calls for a health plan to implement written policies to ensure members’ 

access to non-network providers when a covered service is not available from in-network 

providers, or in emergencies. 

 P-NM 4 - Out of Network and Emergency Services 

To the extent it is contractually responsible, the organization implements written policies that 

assure consumers' access to: 

(a) Covered services that are not available from participating providers; and 

(b) Emergency care, both within and outside the organization's service area. 

Interpretive Guidance:

• Organizations have an obligation to provide for consumers’ medical care, even when 

necessary care is not available within the provider network, or when the consumer has a 

medical emergency. 

• The organization’s policies regarding emergency services must address events both 

within and outside the organization’s service area. 

• Note: All elements of the standard are mandatory. 

• To be effectively implemented, written policies and/or documented procedures that meet 

the intent of this standard must be understood not only by network management staff, but 

also by any employee of the organization that may be called upon to explain to the 

consumer the policy regarding consumer access to emergency services or providers of 

services not available within the network. 

• Consumer documents should include information about how to obtain emergency care, 

including the organization’s policy on when and how to directly access emergency care 

services. 

CONCLUSION

URAC appreciates this opportunity to provide our health care accreditation expertise and 

standards to help the Departments ensure MHPAEA is implemented in a manner that achieves 

this new statute’s intent, and best serves the interests and needs of U.S. health care consumers. 

We hope our comments have been helpful, and invite you to learn more about URAC’s 

accreditation standards, governmental recognitions, operational reviews and additional resources 

by accessing the policy maker portal on the URAC website 

(http://www.urac.org/policyMakers/resources/). 
1220 L Street NW, Suite 400 ♦ Washington, D.C. 20005 ♦ Phone (202) 216-9010 ♦ Fax (202) 216-9006 ♦ www.urac.org 7

Please do not hesitate to contact URAC Vice President for Government Relations, Product 

Development and Education John DuMoulin (jdumoulin@urac.org, 202/962-8836) and URAC 

Government Relations Director Mara Osman (mosman@urac.org, 202/962-8838) if further 

URAC input or assistance is required. 

Thank you for consideration of these comments. 
1220 L Street NW, Suite 400 ♦ Washington, D.C. 20005 ♦ Phone (202) 216-9010 ♦ Fax (202) 216-9006 ♦ www.urac.org 8

APPENDIX A 

OVERVIEW OF URAC

URAC is an independent, nonprofit organization whose mission is to promote continuous 

improvement in the quality and efficiency of health care management through the processes of 

accreditation, education and measurement. Our strategic priorities are to: 

• Enhance Continuity of Care; 

• Encourage Transparency: Cost & Performance/Quality Data; 

• Engage Consumers in their Health Care Management; 

• Enhance Operational Management Effectiveness; and 

• Engender Support for Evidence-Based Decision-Making

To support these goals, our Board of Directors represents the full spectrum of stakeholders 

interested in our health care system, including consumers, employers, health care providers, 

health insurers, purchasers, workers’ compensation carriers and regulators. 

Incorporated in 1990, URAC pioneered utilization management accreditation by creating a 

nationally recognized set of standards to ensure accountability in managed care determinations of 

medical necessity. As the health care industry evolves, URAC continues to address emerging 

issues: we now offer over 25 accreditation and certification programs across the health care 

spectrum: 

• Case Management 

• Claims Processing 

• Consumer Education and Support 

• Core Organizational Quality 

• Credentialing Support 

• Credential Verification Organization 

• Disease Management 

• Drug Therapy Management 

• Health Call Center 

• Health Content Provider 

• Health Network 

• Health Plan 

• Health Provider Credentialing 

• Health Utilization Management 

• Health Web Site 

• HIPAA Privacy 

• HIPAA Security 

• Independent Review Organization 

• Mail Service Pharmacy 

• Medicare Advantage Deeming 

• Pharmacy Benefit Management 

• Specialty Pharmacy 
1220 L Street NW, Suite 400 ♦ Washington, D.C. 20005 ♦ Phone (202) 216-9010 ♦ Fax (202) 216-9006 ♦ www.urac.org 9

• Vendor Certification 

• Wellness 

• Workers’ Compensation Pharmacy Benefit Management 

• Workers’ Compensation Utilization Management 

Government Recognition of URAC Accreditation

Federal and state policymakers recognize the value of private accreditation to promote costefficiency and to ensure that their constituencies receive quality health care. At the federal level,

four federal agencies recognize URAC accreditation. The Centers for Medicare and Medicaid 

Services recognize URAC Medicare Advantage Health Plan Accreditation for the Medicare 

Advantage (formerly Medicare+Choice) Program; the Office of Personnel Management 

recognizes all URAC accreditation programs under the Federal Employee Health Benefits 

Program; TRICARE/Military Health System recognizes URAC’s Health Network Accreditation, 

Case Management, Disease Management, and Utilization Management Accreditations; and the 

Department of Veterans’ Affairs recognizes URAC’s Health Call Center Accreditation. 

Many states have found URAC’s accreditation standards helpful in meeting regulatory 

requirements for managed care plans and other health care organizations and functions. Thirtynine states and the District of Columbia currently reference accreditation through statute, 

regulation, agency publication, Request for Proposal or contract language, making URAC the 

most recognized national managed care accreditation body at the state level. 

URAC Standards: Establishing Quality Benchmarks

URAC accreditation serves as a symbol of excellence in the health care industry, promoting 

prevailing industry standards and consumer protections. In the rapidly evolving field of health 

care, URAC standards are developed through a dynamic process that identifies best practices and 

promotes high quality performance measurement. All stakeholders in the health care arena 

actively participate with URAC in developing these quality benchmarks through an inclusive 

process that incorporates an opportunity for public comment. 

URAC’s standards development process begins with a period of careful research, debate and 

discussion among stakeholders. An initial set of standards is then proposed and made available 

for a public comment and review. URAC’s advisory committees review the submitted 

comments, make appropriate changes, and the draft standards are then beta tested with a discrete 

group of companies in order to ensure that they work in practice. After beta testing, the 

standards may be modified again, and then they are forwarded to URAC’s Board of Directors for 

consideration and approval. URAC revises its standards through this process at least every three 

years. 

URAC Accreditation Review Process

The URAC accreditation review process begins with applicants for accreditation submitting 

material through AccreditNet, URAC’s secure online application system. When an application 
1220 L Street NW, Suite 400 ♦ Washington, D.C. 20005 ♦ Phone (202) 216-9010 ♦ Fax (202) 216-9006 ♦ www.urac.org 10

arrives, a reviewer is assigned to conduct an assessment of the submitted documentation for 

compliance with URAC standards. Any standard that appears non-compliant is noted and 

communicated to the client with a recommended course of action to meet the standard. Then an 

onsite review is conducted for each applicant. 

URAC staff reviewers are clinical experts who provide application support through the entire 

accreditation process, including a sharing of best practices during the onsite review. The 

objective of the onsite review is to verify operational compliance with URAC standards. URAC 

reviewers, for example, interview the applicant’s staff and review a statistically valid sampling 

of relevant documentation, including specific quality information. With respect to quality data, 

URAC accepts nationally recognized measures, such as HEDIS measures to evaluate plan 

performance and CAHPS data to evaluate consumer satisfaction. URAC may also consider other 

credible, CMS-recognized quality measures such as the Wisconsin MEDDIC-MS and MEDDICMS SSI Performance Measures. 

The findings from an applicant’s onsite review are anonymously presented to the URAC 

committees that make the accreditation determinations through an Executive Summary report. 

Committee members include industry peers and experts such as physician providers, plan 

physicians, quality management professionals, information technology experts, pharmacists and 

security/privacy officials. Levels of accreditation are awarded in accordance with corporate 

policy and URAC’s accreditation scoring methodology. Applicants receive an official 

notification letter with their accreditation status and a certificate of accreditation. 

URAC Accreditation Standards-At-A-Glance

URAC accreditation programs are comprised of modules, or sets of standards. The Core 

Organizational Quality Standards serve as the foundation of URAC accreditation, and this 

module is part of each URAC accreditation program, with the exception of URAC’s Health 

Information Technology accreditations. The Core standards address several key organization 

functions that are important for any health care organization: 

URAC Core Organizational Quality Standards 

Organizational Structure Defined Communication Practices Monitored 

Policies and Procedures Articulated Confidentiality Maintained 

Clinical Oversight Access to Services 

Staff Qualifications Defined Promotes Consumer Safety 

Staff Credentialing Enforced Promotes Consumer Satisfaction 

Robust Staff Training Rigorous Complaints and Appeals 

Rigorous Information Management 

Rigorous Regulatory Compliance 

Quality Management Program Defined 

Delegation to Business Partners Monitored Robust Quality Improvement Projects 

HIT Business Continuity Plans (2009) Health Literacy (2009) 
1220 L Street NW, Suite 400 ♦ Washington, D.C. 20005 ♦ Phone (202) 216-9010 ♦ Fax (202) 216-9006 ♦ www.urac.org 11

URAC Health Utilization Management Accreditation is URAC’s premier program. Pioneered in 

1990, it presented the first-ever industry standards for utilization management and transformed 

the industry. URAC Health Utilization Management Standards serve as the basis for many states’ 

laws and regulations and are the most widely recognized utilization management standards at the 

state and federal level. The standards address key issues in medical necessity decisions: 

URAC Health Utilization Management Standards 

Review Criteria Time Frames for Initial UM Decision

Accessibility of Review Services Notice of Non-Certification Decisions 

On-site Review Services Notice of Certification Decisions 

Initial Screening UM Procedures 

Initial Clinical Review 

Peer Clinical Review 

Information Upon Which UM is Conducted 

Peer-to-Peer Conversation Appeals Considerations 

FEDERAL RECOGNITIONS (In Detail) 

1. Centers for Medicare and Medicaid Services (CMS) recognize URAC Medicare 

Advantage Health Plan Accreditation for the Medicare Advantage (MA) Program. 

CMS granted URAC deemed status in May 2006 for both local PPO and HMO health plans 

approved under its Medicare Advantage Deeming Program. Deemed status is official recognition 

by the nation’s third largest payer that URAC accreditation meets or exceeds CMS’s own 

regulatory standards for plan quality in six areas: quality assessment and improvement; 

confidentiality and accuracy of enrollee records; antidiscrimination; access to services; provider 

participation rules; and advance directives. CMS’s approval of URAC for deeming authority was 

published in the Federal Register on Friday, May 26th, 2006. Deeming authority is granted 

based on CMS’s determination that URAC’s standards are at least as stringent as those specified 

under Medicare. 

Should an Medicare Advantage (MA) organization receive accreditation from a CMS approved 

accrediting organization such as URAC, as an alternative for meeting some Medicare 

requirements, an MA organization may be exempt from CMS monitoring of certain requirements 

in subsets listed in section 1852(e)(4)(B) of the Social Security Act. In essence, the Secretary 

deems that the MA organization has met the Medicare requirements via its accreditation (by 

URAC or other accrediting organization approved by CMS). 

2. The Office of Personnel Management (OPM) recognizes all URAC accreditation 

programs under the Federal Employee Health Benefits Program (FEHBP). 

The FEHBP provides health care coverage to approximately eight million federal employees, 

retirees, and their dependents. Since July 2000, URAC accreditation has been listed in the annual 

Guide to Federal Employees Health Benefits. 
1220 L Street NW, Suite 400 ♦ Washington, D.C. 20005 ♦ Phone (202) 216-9010 ♦ Fax (202) 216-9006 ♦ www.urac.org 12

3. The TRICARE/Military Health System, the Department of Defense’s managed health 

care program, recognizes URAC Health Network (HN), Case Management (CM), Health 

Utilization Management (HUM), and Disease Management (DM) Accreditations. 

Through TRICARE, the federal government provides health care services throughout the world 

to 8.7 million military personnel and their families and military retirees. 

Tricare first recognized URAC’s Health Network Accreditation in a 2002 Request for Proposals 

(RFP) (Solicitation No. MDA906-02-R-0006, Aug. 1, 2002). In 2008, TRICARE expanded its 

recognition of URAC’s accreditation standards to include case management (CM), health 

utilization management (HUM), and disease management (DM). The 2008 RFP (Solicitation No. 

H94002-07-R-0007, March 24, 2008) requires contractors’ networks and utilization and case 

management programs to be “accredited by a nationally recognized accreditation organization no 

later than 18 months after the start of health care delivery” and that the accreditations be 

maintained “in all geographic areas covered by the contract” and “throughout the contract and all 

exercised options.” The RFP further requires that the contractor’s disease management programs 

“meet national accreditation standards for disease management and chronic care management” 

within the 18 month time frame. TRICARE has specifically identified URAC as a nationally 

recognized accreditation organization. 

4. The Department of Veterans’ Affairs (VA) recognizes URAC Health Call Center 

Accreditation. 

The Veterans Health Administration (VHA) has 22 regional Veterans Integrated Service 

Networks (VISNs) that were instituted to administer the health services for VA hospitals and 

clinics. (The VHA has 173 medical centers, 650 outpatient community and outreach clinics, and 

over 51,000 medical center beds with the VHA treating nearly one million patients a year in VA 

hospitals alone.) In Directive 2000-035 (October 5, 2000), the VHA established as policy that 

each VISN must ensure that all of its enrolled patients are provided 24x7 direct telephone access 

to clinical staff who are trained to provide health care advice and information. These telephone 

care programs/call centers must meet specified minimum standards and must get accredited by 

URAC or another appropriate accrediting body. URAC is currently the only accrediting body for 

telephone care and triage call centers. 
Health Utilization Management Standards, Version 6.0
Table of Contents

Copyright for Health Utilization Management 2008....................................................................................................1

 Message from URAC......................................................................................................................................................2

Introduction to URAC Accreditation Guides and Standards......................................................................................4

Scoring Methodology.......................................................................................................................................................8

Definitions for Health Accreditation Standards.........................................................................................................17

Crosswalk between Core v2.1 & v3.0...........................................................................................................................39

Core v3.0 Consumer-Facing Accreditations................................................................................................................42

Applicability of Core Organizational Quality Standards, Version 3.0.....................................................................45

CORE, Version 3.0.........................................................................................................................................................49

Organizational Structure.....................................................................................................................................49

Policies and Procedures......................................................................................................................................49

Regulatory Compliance......................................................................................................................................50

Inter-Departmental Coordination........................................................................................................................50

Oversight of Delegated Functions......................................................................................................................50

Marketing and Sales Communications...............................................................................................................52

Business Relationships........................................................................................................................................52

Information Management....................................................................................................................................52

Quality Management...........................................................................................................................................54

Staff Qualifications.............................................................................................................................................57

Staff Management...............................................................................................................................................57

Clinical Staff Credentialing and Oversight Role................................................................................................58

Health Care System Coordination......................................................................................................................60

Consumer Protection and Empowerment...........................................................................................................60

Health Utilization Management , Version 6.0.............................................................................................................62

Review Criteria...................................................................................................................................................62

Accessibility of Review Services........................................................................................................................62

On-Site Review Services....................................................................................................................................63

Initial Screening..................................................................................................................................................63

Initial Clinical Review........................................................................................................................................64

Peer Clinical Review...........................................................................................................................................65

Peer-to-Peer Conversation..................................................................................................................................65

i
Table of Contents

Health Utilization Management , Version 6.0

Time Frames for Initial UM Decision................................................................................................................66

Notice of Certification Decisions........................................................................................................................68

Notice of Non-Certification Decisions...............................................................................................................68

UM Procedures...................................................................................................................................................69

Information Upon Which UM is Conducted......................................................................................................69

Appeals Considerations......................................................................................................................................70

ii
Copyright for Health Utilization Management 2008

Health Utilization Management Standards, Version 6.0, August 2008

Previous versions:

Health Utilization Management Standards, Version 5.1, April 2007

 Health Utilization Management Standards, Version 5.0, January 2006

Health Utilization Management Standards, Version 4.2, April 2003

Health Utilization Management Standards, Version 4.1, July 2002

Health Utilization Management Standards, Version 4.0, November 2001

Health Utilization Management Standards, Version 3.0, June 1997

National Utilization Management Standards, 1994

National Utilization Review Standards, 1991

© URAC 2008

1220 L Street, NW, Suite 400, Washington, DC 20005

Ph:(202) 216-9010

Fax:(202) 216-9006

www.urac.org

All rights reserved. Permission is hereby granted for reproduction for internal distribution by URAC-accredited

companies or applicants. Other reproduction by any means in whole or part without written permission is prohibited.

1
Message from URAC

Dear interested party or applicant:

Quality-based operations should be the centerpiece of any company doing business in today’s health care system.

Quality improvement activities promote a wide range of benefits such as increasing operational efficiencies, reducing

business risks and improving patient health outcomes. However, health care professionals must identify and

implement a quality improvement methodology that really works for their particular business model and health care

setting.

Through its modular approach to accreditation, URAC works with the industry and other key stakeholders to

benchmark URAC standards against key organizational structures and business functions. Now in its 18th year of

operation, URAC offers 20 different accreditation and certification programs. URAC has issued more than 10,000

accreditation certificates to companies operating in all 50 states and internationally. URAC also is recognized as part

of the regulatory process in three-fourths of the states and by four federal agencies.

URAC, as a nonprofit, independent accreditation agency, brings to the table a nationally-recognized accreditation

process and seal of approval. URAC’s success is tied in large part to the broad-based, consensus-driven process by

which hundreds of volunteers help URAC draft and update its standards and also oversee the accreditation system. 

These volunteers represent the interests of a wide variety of stakeholders including purchasers, regulators, consumers,

providers and industry representatives.

All companies that apply for URAC accreditation make improvements to their operations as a result of the review

process. The desktop review of the application identifies issues early on in the process and helps focus the onsite

review, which is designed to confirm compliance with the standards. During the onsite visit, accreditation reviewers

exchange information with applicants in what often becomes a mutual learning experience. URAC’s goal is to

identify and promote best practices for each market segment that it accredits.

Receiving the accreditation certificate signifies a job well done and distinguishes the organization as having met a

standard of excellence. As a result, URAC accredited organizations join the ranks of a select community who have

documented and verified their commitment to quality health care.

Please contact URAC if you would like to find out more about the accreditation process or to become involved with

one of our committees, educational programs, research initiatives, or other projects. We look forward to hearing from

you.

2
3
Introduction to URAC Accreditation Guides and

Standards

URAC offers two references addressing standards. The Accreditation Standards provides a copy of the

standards produced by URAC and defined terms, which are italicized within the standards. It is a resource

for government agencies and private entities wanting to examine the standards for their own purposes. 

For organizations contemplating accreditation, URAC's Accreditation Guide provides, in addition to the

standards, information about the documentation to submit as evidence for meeting the intent of the

standards as well as the types of materials and activities URAC's accreditation reviewers will be examining

during an onsite visit. Both the Accreditation Standards and Guide are available through URAC’s Business

Development Department at (202)216-9010 or send an e-mail to BusinessDevelopment@urac.org. For

detailed information about how to prepare an application for accreditation, please go to:

http://www.urac.org/healthcare/accreditation/accreditnet.aspx for a copy of the AccreditNet Instruction

Booklet, designed to complement the Accreditation Guide for applicant organizations.

The Accreditation Standards and Accreditation Guide are intended to provide guidance only. The

URAC Accreditation Committee and Executive Committee hold the final authority to make

determinations regarding interpretation and application of standards, and an applicant's

compliance with standards.

The Accreditation Guide is provided to assist applicants understand the meaning or intent of the

standards. That being said, it cannot cover all possible situations and subsequent interpretations that may

apply. Therefore, applicants should be aware that the standards are subject to ongoing interpretation and

as such, changes can be made to the Accreditation Guide.

Each company applying for accreditation should carefully review URAC's accreditation standards and the

defined terms italicized within the standards, then use the Accreditation Guide and AccreditNet Instruction

Booklet to prepare an application for submittal to URAC. 

Modular Concept

URAC uses a “modular accreditation system” that is adaptable to the continuing evolution of the health

care system. A module is a set of standards established for a particular health care function. The

collection of standards contained within modules are unique to that health care service or function. The

Core Standards incorporate the basic elements necessary to promote quality for any type of health care

organization and were designed for two purposes: 1) to act as a “foundation” for function-specific

accreditation programs, and 2) to act as a “stand-alone” accreditation program for companies not

delivering services under one of the specific functions or modules.

Each accreditation will include Core and the module(s) covering the functions.

4
 Core Standards + Module(s) = Specific Accreditation

Core “stand-alone” accreditation will only consist of Core Standards.

 Core Standards Only = Core “Stand-Alone” Accreditation

Eligibility to apply for Core “stand-alone” accreditation is determined on the basis of how a company

markets itself. If a health care organization markets any of the services addressed under one of URAC’s

modules, Core “stand-alone” accreditation is not an option. An example of an organization that would be

eligible for Core “stand-alone” accreditation is an organization that provides health care educational

services.

For applicants, the modular system provides the flexibility to choose from a variety of accreditation

programs. For example, an applicant may choose to apply for Utilization Management (UM) accreditation

initially, and when up for reaccreditation, add the Case Management (CM) module.

Core with Single-Module Application (Example: Core & UM only)

Core with Multi-Module Application (Example: Core & UM + CM)

With several choices available, an applicant can tailor the accreditation to its current needs and business

goals. If you are not sure what modules would best fit your organization, URAC’s Business Development

Department can be reached at BusinessDevelopment@urac.org or at (202) 216-9010 to answer questions,

provide pricing information and help organizations decide the best course of action.

Compliance with State and Federal Law

The Accreditation Guide provides information on URAC's expectations regarding compliance with each

standard. Some standards require applicants to attest to compliance with specific state regulations

regarding operational policy and procedure. Prior to submitting an application the applicant should

conduct a review of its legal obligations, including those addressed in the standards. Although it is not

indicated for each standard, URAC expects that the applicant will be in compliance with all applicable state

and federal laws that pertain to relevant operations. State and federal laws supersede URAC Standards if

the laws or regulations are more rigorous than URAC Standards. Conversely, an applicant must comply

with URAC Standards if the standards are more stringent. If an applicant is required by law to carry out its

business in a manner not consistent with URAC Standards, then the applicant may request a variance

from a URAC Standard. A copy of the relevant statute or regulation must accompany the request

submitted for that standard in the application.

Standards and Interpretation

5
The standards are grouped together into modules, with each module representing various health care

functions. Individually, the standards address the structures and processes that need to be in place for

performing the function to be accredited according to national standards. For the most part, an applicant is

expected to be in compliance with all applicable standards at the time of application for accreditation.

 In the Accreditation Standards, you will find:

 * Definitions. All italicized terms found in the standards are defined in this section.

 * Standards with assigned Weights. Standard elements include assigned weights for scoring. If an

element in and of itself does not contain enough information to evaluate compliance without the following

sub-element, then it is noted as "Not Weighted." 

In the Accreditation Guide, you will find:

 * Definitions. All italicized terms found in the standards are defined in this section.

 * Standards with assigned Weights and Interpretive Information for each Standard. 

 * Points to Remember and Scope of Standards. These bullet points identify important issues to

consider when documenting your organization’s compliance with the standard. In some cases, additional

details are provided that will help your compliance efforts and in other cases, these details will alert you to

potential pitfalls.

 * Evidence for Meeting the Standards: Desktop Materials and Onsite Review Materials and

Activities.

 * Bright Ideas. This section is not used for every standard and contains common industry practices that

may be helpful to the applicant organization. (Note: adoption of a “bright idea” is not required for

compliance with a standard, nor does adoption of the “bright idea” guarantee compliance with that

standard.)

 * Related Standards. This section is not used for every standard, but helps to identify relationships

between standards that are not always obvious and helpful to know about.

6
7
Scoring Methodology

Policy Regarding “Not Applicable” Elements and Standards

If a weighted standard element or an entire standard is determined to be not applicable, then they are not

included in the scoring calculations (i.e., deducted from the denominator). This includes the rare instance

when a “variance” is granted by the requisite URAC committee. As a result, applicants are not penalized

when a standard element or standard is not applicable.

If a mandatory standard element is determined to be not applicable, then it does not count against the

applicant when determining an accreditation category; however, applicant organizations must have a

policy that meets the intent of a mandatory standard element even if it is not currently being implemented.

An applicant may choose not to meet any or all leading indicator standard elements (i.e., leading indicators

are optional); therefore, a leading indicator standard element, which is not weighted, cannot be made not

applicable. Not all accreditation standard sets have leading indicators.

Standard Element Weights

URAC’s Scoring System has six (6) distinct categories of standard elements:

· Weight = 1: Emerging Practice

· Weight = 2: Basic Infrastructure

· Weight = 3: Promotes Quality

· Weight = 4: Key Stakeholder Right / Empowers Consumers

· Mandatory = M: Non-weighted, mandatory element with a direct or significant impact on consumer

safety and welfare

o All mandatory elements must be met at 100% compliance in order to achieve a Full

accreditation

o If determined to be not applicable, applicant must have a policy and procedure in place that meets

the intent of the element should the organization need to implement it in the future

· Leading Indicator = L: Non-weighted, optional element highlighting effective practices not yet widely

adopted in health care

o Potential forecast of where the health care industry may be heading

8
o Provides a way for an organization to distinguish itself from other accredited companies

o Leading indicators are not reported to URAC’s Accreditation or Executive Committees and

do not influence an applicant’s final accreditation score or category

o Cannot be designated “not applicable” given that they are optional

o Before URAC will acknowledge that an applicant has met a leading indicator:

- Full accreditation must be achieved, and

- Element must be met at 100% compliance

- Initially URAC will list leading indicators in the Accreditation Summary Report (ASR)

o Other types of marketing exposure may be considered in the future (e.g., Website, conferences,

etc.)

Definitions for the standard element categories are listed on the following pages. As you analyze the

standard elements to assign a weight, keep in mind the following:

Standards are no longer weighted, but standard elements are. Elements are the components of a

standard that are evaluated through the accreditation review process.

• 

• Standard elements are no longer designated as “primary” or “secondary.”

Computing an Accreditation Score

• Scoring an Element

o Element weight x Compliance

• Scoring a Standard

o Total points achieved ÷ Total points possible

• Scoring a Module

o Total points achieved ÷ Total number of standards

• Scoring a multi-Module accreditation

o (Core score x .30) + (Module score x .70)

9
• Scoring a multi-Site accreditation

o Lowest site score determines the application score

Determining an Accreditation Category

• If one Mandatory standard element is not met Conditional

• If two Mandatory standard elements are not met Corrective Action

• If three Mandatory standard elements are not met Denial

• If all Mandatory standard elements are met:

≥ 94 points/100 and complies 100% on at least one “Leading Indicator” standard à Include compliance with

Leading Indicator(s) on the Accreditation Summary Report (ASR)

 ≥ 94 points/100 Full Accreditation

 ≥ 90, but < 94 points/100 Conditional Accreditation

 ≥ 85, but < 90 points/100 Corrective Action

 < 85 points/100 Denial

Rating Compliance with a Standard Element

Standard elements are individually rated at 100% (full compliance), 50% (partial compliance) or 0% (no

compliance) as follows:

For elements that require a file/record audit, the audit must reveal:

% Compliance with Element

100% Compliance (Full Compliance) = Audit score ≥ 80%;

Note: A mandatory element must be met at 100% compliance with an audit score of ≥ 90%; if not, then the

mandatory element is considered not met. Credentials verification must be met at 100%. Applicants must

meet all applicable mandatory elements in order to achieve Full accreditation.

Note: A leading indicator element must be met at 100% compliance; if not, then the leading indicator is

considered not met. Applicants do not have to meet leading indicators since these types of elements are

optional, acting as “extra credit.”

10
Note: A minimum of 30 files will be pulled for file review, but if the applicant does not have 30 files, then all

files will be reviewed. For monitoring reviews, files will be pulled from the first 12 months of the

accreditation cycle; for reaccreditation reviews, files will be pulled from the prior 24 months.

50% Compliance = Audit score ≥ 65%, but < 80%, or for contracts the audit score is < 80%, but the

applicant has an internally approved, compliant contract template.

• 

0% Compliance = Audit score < 65%, or for contracts the applicant does not have an internally

approved, standards-compliant contract in place.

• 

For elements that do not require a file/record audit:

% Compliance with Element

100% Compliance (Full Compliance) = Element documented pursuant to the standard element and upon

verification is found to be fully implemented.

Note: A mandatory element must be met at 100% compliance; if not, then mandatory element is

considered not met. Applicants must meet all applicable mandatory elements in order to achieve Full

accreditation.

Note: A leading indicator element must be met at 100% compliance; if not, then the leading indicator is

considered not met. Applicants do not have to meet leading indicators since these types of elements are

optional, acting as “extra credit.”

· A standard element is implemented, where at least one of the following onsite activities is verified:

o Staff is observed conducting the procedure correctly; or

o Staff verbalizes the procedure correctly; or

o Documented examples of implementation are surveyed; or

o Documentation of oversight is reviewed; or

o Management attests to its implementation and provides supporting documentation (i.e., sign-in

sheets showing staff training session occurred, CV of newly hired medical director, sample of revised and

11
distributed documentation such as a provider directory, notification letters, etc.)

· 50% Compliance (Partial Compliance) = Element documented pursuant to the standard element, but

not consistently or completely implemented. 

· One or more incidences of non-compliance in implementation will lower the compliance rating

to 50%. This would include:

o Errors implementing work processes during on-site observation by the URAC Reviewer.

o Mistakes during interviews. If staff catches the error – misspoke – and corrects it, then this will not

count as evidence of non-compliance.

o Reports with data or analysis demonstrating non-compliance (e.g., not meeting timelines, wrong

staff conducted the procedure, provider listed in a directory prior to credentialing, etc.)

o Meeting minutes revealing decisions contrary to meeting the intent of the standards or lacking

documentation indicating that a key activity did not take place (e.g., vote to eliminate provider appeal

mechanism, minutes do not reflect review and update of the quality management program, etc.) 

0% Compliance (No Compliance) = No evidence or incomplete evidence of compliance with the standard

element in documentation or, regardless of documentation, applicant has not implemented the structures

or processes needed to comply with the standard element. No compliance is exemplified when any one of

the following statements is true. 

The standard element is:

· Not addressed in documentation,

· Only partially addressed in documentation,

· Addressed in documentation, but does not meet the intent of the standard element,

· Not implemented, which does not include situations where:

o The organization did not have the opportunity to implement. An example of this would be where an

organization has an appeal process in place, but is either not contracted to do appeals or simply has not

had an appeal of the type addressed by the standard.

o The organization has been in business < six (6) months and is therefore eligible for a provisional

accreditation.

12
· Implemented in a non-compliant manner, or

· Implemented, but one or more staff shows a pattern (≥ 4 occurrences) of non-compliance with an

element over a period of time (within six (6) consecutive months), regardless of any warnings, corrective

action taken (including training or procedural changes), or relative improvement over time.

 Scoring a Weighted Standard Element

 To score a weighted standard element (“element”),

Multiply the element weight by the compliance factor achieved (e.g., 0 for no compliance, .50 for

partial compliance or 1.0 for full compliance).

• 

Calculation for Standard Element Score

(Compliance factor) × (Weight of standard element) = Score for an Element

Scoring a Standard

 To score a standard with weighted elements,

• Sum the score achieved for each element.

• Divide by the number of points possible (sum of the element weights) for the entire standard. 

o Weights for the elements determined to be not applicable are not included in the denominator and

as such do not count against the applicant. 

• Multiply by 100; this provides a percentage score for the standard.

Calculation for Standard Score

[(Sum of all applicable element scores) ÷ (Total possible points for the standard)] × 100 = Standard Score

Calculating a Final Total Accreditation Score for Core-only Applications and Accreditations that do

not include Core

To calculate a final score for Core-only and non-Core Module Applications,

• Sum the scores for each standard.

• Divide by the total number of applicable standards.

o Standards determined to be not applicable are not included in the denominator and as such do not

13
count against the applicant.

Calculation for Core and non-Core Module Score

[(Sum of all applicable standard scores) ÷ (Total number of applicable standards)] = Module Score = Final

Total Score (round to nearest tenth)

Note: For purposes of calculating an accreditation score, the number of standards possible is the total

count of standards that have at least one weighted element; standards that do not have any weighted

elements (i.e., only mandatory and/or leading indicator elements) are not included in the count since they

do not contribute a standard score towards the module score. It is not logical to include standards in the

denominator when it has no points to contribute to the score and to include such a standard in the

denominator would unfairly penalize the applicant.

Note: If all weighted elements in a standard are determined to be not applicable, then the standard does

not count towards the total number of applicable standards for purposes of scoring a module. To count

them would unfairly penalize the applicant and is contrary to the URAC policy on standards determined to

be not applicable. 

Calculating a Final Total Accreditation Score for Multi-Module Accreditations

To calculate a final total accreditation score for multi-module accreditations, which includes:

· Core + a single Module (e.g., Health UM, IRO, CES, etc.)

· Core + multiple Modules (e.g., Health Plan, Health Network, etc.) 

For Core:

• Sum all of the Core standard scores.

• Divide by the total number of applicable standards.

o Standards determined to be not applicable are removed from the denominator and as such do not

count against the applicant.

Multiply the Core score by .30 since Core is 30% of the final score for multi-module accreditations

that include Core.

• 

For non-Core module score:

• Sum all of the standard scores from all of the non-Core modules.

• Divide by the total number of applicable standards.

14
o Standards determined to be not applicable are removed from the denominator and as such do not

count against the applicant.

Multiply the non-Core score by .70 since the non-Core modules collectively contribute to 70% of the

final score.

• 

• Sum the percentage score for Core and the modules; a perfect score would be 100%.

Final Total Score

(Core score × .30) + (non-Core score × .70) = Final Total Score for One or Multiple Sites (round to nearest

tenth)

Final Total Score if all Sites achieve a Full (≥ 94)

(Sum of all Full onsite scores) ÷ (Number of sites that had an onsite review) = Final Full Accreditation

Score (round to nearest tenth)

Note:

· Each site that has an onsite review receives its own score; however, the lowest of these scores

determines the score for the overall application.

· If all sites receiving an onsite review achieve a Full, the average score for these sites is the final

score for the application. (See calculation above.)

· If there is a trend of three (3) or more sites that achieve less than a Full accreditation, then the

URAC Reviewer has the discretion to visit all of the sites in the application.

Determining How Many Mandatory Elements are Met and Not Met

Mandatory elements are non-weighted elements and all applicable mandatory elements must be met at

100% compliance in order for an applicant to achieve Full accreditation.

Mandatory elements that are determined to be not applicable are subtracted from the total count of

mandatory elements and do not count against an applicant.

• 

Mandatory elements with a compliance level less than 100% (e.g., partial compliance [.5] and no

compliance [0]) are considered not met and count against an applicant when determining an

accreditation level. (See “Determining an Accreditation Level” below.)

• 

15
16
Definitions for Health Accreditation Standards

(NOTE: Defined terms appear in italics throughout the standards).

Being familiar with these definitions is critically important to accurate understanding of URAC Standards. In

the Standards, defined terms are italicized. Readers are encouraged to refer to the definitions section each

time they encounter an italicized term until they feel they have committed the meaning of that term to

memory.

Abandonment Rate: The percentage of calls offered into a communications network or telephone system

-- i.e., automatic call distribution (ACD) system of a call center -- that are terminated by the persons

originating the call before answer by a staff person.

 Interpretive note for term "Abandonment Rate": Abandonment rate is measured as the percentage of calls that

disconnect after 30 seconds when an individual (live person) would have answered the call. For example, if there is a

pre-recorded message or greeting for the caller, the 30-second measurement begins after the message/greeting has

ended. (On ACD reports, monitor calls that "drop" after 30 seconds.)

Access: The consumer’s or client's ability to obtain services in a timely manner.

Interpretive Note: The measures of access for consumers are determined by components

such as the availability of services, their acceptability to the consumer, consumer wait time,

and the hours of operation.

The measures of access for clients are determined by components such as turn-around

time and other metrics as they may be defined in written business agreements, etc.

Adverse Benefit Determination: A decision by the Organization to deny or reduce a benefit for some or

all of the lines of a claim (other than the application of a deductible or other cost-sharing).

Adverse Event: An occurrence that is inconsistent with or contrary to the expected outcomes of the

Organization’s functions.

17
Advisory Board of Osteopathic Specialists (ABOS): American Osteopathic Association (AOA)

certification agent organized in 1939 for the purpose of establishing and maintaining standards of

osteopathic specialization and pattern of training.

American Board of Medical Specialties (ABMS): Organized originally in 1933 as the Advisory Board of

Medical Specialties, the ABMS (1970), in collaboration with the American Medical Association (AMA), is

the recognized certifying agent for establishing and maintaining standards of medical specialization and

pattern of training.

Appeal: A written or verbal request by a consumer, ordering provider or prescriber to contest an

organizational determination (e.g., services have been denied, reduced, etc.).

Interpretive Note for term “Appeal”: Specific terms used to describe appeals vary, and are often

determined by law or regulation.

Appeals Consideration: Clinical review conducted by appropriate clinical peers, who were not involved

in peer clinical review, when a decision not to certify a requested admission, procedure, or service has

been appealed. Sometimes referred to as “third level review.”

Assessment: A process for evaluating individual consumers that have been identified as eligible for the

disease management program, to identify specific needs relating to their clinical condition and associated

co-morbidities. 

Attending Physician: The doctor of medicine or doctor of osteopathic medicine with primary

responsibility for the care provided to a patient in a hospital or other health care facility.

Attending Provider: The physician or other health care practitioner with primary responsibility for the care

provided to a consumer.

18
Average Speed of Answer: The average delay in seconds that inbound telephone calls encounter

waiting in the telephone queue of a call center before answer by a staff person.

 Interpretive note for term "Average Speed of Answer": The speed of answer is measured starting at the

point when an individual (live person) would have answered the call. For example, if there is a pre-recorded message

or greeting for the caller, the time it takes to respond to the call (i.e., average speed of answer) begins after the

message/greeting has ended.

Benefit Calculation: An adjustment or calculation by the Organization of the financial reimbursement

for a claim under the terms of the applicable benefit plan, provisions, criteria, provider contracts, or state

rules.

Benefits Program: An arrangement to pay for health care services provided to a consumer. “Benefits

program” includes, but is not limited to, health and medical benefits provided through the following

organization types:

• Health maintenance organizations (HMOs);

• Preferred provider organizations (PPOs);

• Indemnity health insurance programs;

• Self-insured plans;

• Public programs, such as Medicare and Medicaid; and

• Workers’ compensation insurance programs.

Blockage Rate: The percentage of incoming telephone calls “blocked” or not completed because

switching or transmission capacity is not available as compared to the total number of calls encountered. 

Blocked calls usually occur during peak call volume periods and result in callers receiving a busy signal.

Board-certified: A certification – approved by the American Board of Medical Specialties, the American

Osteopathic Association, or another organization as accepted by URAC – that a physician has expertise in

a particular specialty or field. To the extent that future URAC standards include other certifications, URAC

will specify further approved boards.

Interpretive Note for term “Board-certified”: URAC recognizes that ABMS- and AOA-approved board

certifications may not be the only certification programs that may be acceptable for health professionals in

URAC-certified organizations. For example, non-physician professionals will have appropriate

certifications that are not ABMS- of AOA-approved. Any applicant wishing to have URAC recognize

19
another board certification program should notify URAC early in the certification process. URAC will then

take this recommendation to URAC’s Accreditation Committee. 

The Accreditation Committee will review all requests, and will decide to approve or reject the certification. 

The Accreditation Committee will consider the following criteria in judging whether a certification is

acceptable:

• Is the certification accepted within its target community of health professionals?

• Was the certification developed through an open, collaborative process?

• Does the certification reflect accepted standards of practice?

• Is the certification administered through an objective process open to all qualified individuals?

Caller: The consumer inquiring to obtain health care information. This may also be a representative

inquiring on behalf of the consumer.

Case: A specific request for medical or clinical services referred to an organization for a determination

regarding the medical necessity and medical appropriateness of a health care service or whether a

medical service is experimental/investigational or not. It is a non-approval regarding medical necessity and

medical appropriateness decisions for services covered under a health benefit plan’s terms and conditions

or for coverage decisions regarding experimental or investigational therapies that is at issue during the

independent review process.

Case Involving Urgent Care: Any request for a utilization management determination with respect to

which the application of the time periods for making non-urgent care determinations a) could seriously

jeopardize the life or health of the consumer or the ability of the consumer to regain maximum function, or

b) in the opinion of a physician with knowledge of the consumer’s medical condition, would subject the

consumer to severe pain that cannot be adequately managed without the care or treatment that is the

subject of the case. (Note: This definition is derived from the Department of Labor’s definition of “claim

involving urgent care.”)

Interpretive Note for term “Case Involving Urgent Care”:

While the URAC standards are silent on the methods by which a claim is determined to be a “case

involving urgent care,” the Department of Labor claims regulation (29 C.F.R. § 2560.503-1(m)(1)) specifies

that whether a claim is a “claim involving urgent care” is to be determined by an individual acting on behalf

of the health benefits plan applying the judgment of a prudent layperson who possesses an average

knowledge of health and medicine. Any claim that a physician with knowledge of the claimant's medical

condition determines is a “claim involving urgent care” shall be treated as a “claim involving urgent care.

20
Case Management: A collaborative process which assesses, plans, implements, coordinates, monitors,

and evaluates options and services to meet an individual’s health needs using communication and

available resources to promote quality cost-effective outcomes.

Certification: 

1) (UM Specific Definition) A determination by an organization that an admission, extension of stay, or

other health care service has been reviewed and, based on the information provided, meets the clinical

requirements for medical necessity, appropriateness, level of care, or effectiveness under the auspices of

the applicable health benefit plan. 

Interpretive Note for term “Certification”: “Determination” may vary depending on context.

2) (General Definition) A professional credential, granted by a national organization, signifying that an

individual has met the qualifications established by that organization. To qualify under these standards,

the certification program must:

• Establish standards through a recognized, validated program;

• Be research-based; and

• Be based (at least partially) on passing an examination

Claim: Any bill, claim, or proof of loss made by or on behalf of a consumer or health care provider to an

Organization (or its intermediary, administrator, or representative) for which the consumer or health care

provider has a contract for payment of health care services. (Note: definition based on Code of Virginia §

38.2-3407.15.)

Claimant: A person or entity who submits a claim, or on whose behalf a claim is submitted. (Includes

“consumer” for URAC’s Core Standards.)

Claims Administrator: Any entity that recommends or determines to pay claims to enrollees, physicians,

hospitals, or others on behalf of the health benefit plan. Such payment determinations are made on the

basis of contract provisions. Claims administrators may be insurance companies, self-insured employers,

third party administrators, or other private contractors.

Claims Processing Organization: An organization that seeks accreditation under these standards. 

Examples of organizations that process claims include but are not limited to:

• Health insurance companies;

21
• Health maintenance organizations (HMOs);

• Preferred provider organizations (PPOs);

• Third-party administrators (TPAs);

• Disability insurance carriers; and

• Workers’ compensation insurance carriers.

Interpretive Note for term “Claims Processing Organization”: Throughout this document the term

“organization” refers to claims processing organization.

Clean Claim: A claim that has no material defect, impropriety, lack of any required substantiating

documentation, or special circumstance(s) – such as, but not limited to, coordination of benefits,

pre-existing conditions, subrogation, or suspected fraud – that prevents timely adjudication of the claim.

Client: A business or individual that purchases services from the Organization.

Interpretive Note for term “Client”: Here are some examples of client relationships:

• If a health plan provides health coverage to an employer, the employer is the client.

If a health plan contracts for utilization management services from a utilization management

organization, the health plan is the client.

• 

• If a PPO contracts for credentialing services with a CVO, the PPO is the client.

Clinical Activities: Operational processes related to the delivery of clinical triage and health information

services performed by clinical staff.

Clinical Decision Support Tools: Protocols, guidelines, or algorithms that assist in the clinical

decision-making process.

Clinical Director: A health professional who: (1) is duly licensed or certified; (2) is an employee of, or

party to a contract with, an organization; and (3) who is responsible for clinical oversight of the utilization

management program, including the credentialing of professional staff and quality assessment and

improvement functions.

Clinical Peer: A physician or other health professional who holds an unrestricted license and is in the

same or similar specialty as typically manages the medical condition, procedures, or treatment under

review. Generally, as a peer in a similar specialty, the individual must be in the same profession, i.e., the

same licensure category as the ordering provider.

22
Clinical Practice Guidelines: Systematically developed statements to assist decision-making about

appropriate health care for specific clinical circumstances.

Clinical Rationale: A statement that provides additional clarification of the clinical basis for a

non-certification determination. The clinical rationale should relate the non-certification determination to

the patient’s condition or treatment plan, and should supply a sufficient basis for a decision to pursue an

appeal.

Clinical Review Criteria: The written screens, decision rules, medical protocols, or guidelines used by

the organization as an element in the evaluation of medical necessity and appropriateness of requested

admissions, procedures, and services under the auspices of the applicable health benefit plan.

Clinical Staff: Employees or contracted consultants of the health care organization who are clinically

qualified to perform clinical triage and provide health information services.

Clinical Triage: Classifying consumers in order of clinical urgency and directing them to appropriate

health care resources according to clinical decision support tools.

Comparable: Data about performance is compared to an historical baseline (which may be internal) and

ongoing progress is recorded in regular intervals (e.g., monthly, quarterly, or annually). External

benchmarks also may be used for purposes of comparison.

Complaint: An expression of dissatisfaction by a consumer expressed verbally or in writing regarding an

organization’s products or services that is elevated to a complaint resolution system.

Interpretive Note for term “Complaint”:

• This term is sometimes referred to as “grievance.” 

• This definition does not include appeals.

Concurrent Review: Utilization management conducted during a patient's hospital stay or course of

treatment (including outpatient procedures and services). Sometimes called "continued stay review".

Condition: A diagnosis, clinical problem or set of indicators such as signs and symptoms a consumer may

have that define him/her as eligible and appropriate to participate in a disease management program.

23
Conflict of Interest: Any relationship or affiliation on the part of the organization or a reviewer that could

compromise the independence or objectivity of the independent review process. Conflict of interest

includes, but is not limited to:

• An ownership interest of greater than 5% between any affected parties;

• A material professional or business relationship;

• A direct or indirect financial incentive for a particular determination;

• Incentives to promote the use of a certain product or service;

• A known familial relationship;

• Any prior involvement in the specific case under review.

Consumer: An individual person who is the direct or indirect recipient of the services of the Organization. 

Depending on the context, consumers may be identified by different names, such as “member,” enrollee,”

“beneficiary,” “patient,” “injured worker,” “claimant,” etc. A consumer relationship may exist even in cases

where there is not a direct relationship between the consumer and the Organization. For example, if an

individual is a member of a health plan that relies on the services of a utilization management organization,

then the individual is a consumer of the utilization management organization.

Interpretive Note for term “Consumer”:

In the case of a consumer who is unable to participate in the decision-making process, a family member or

other individual legally authorized to make health care decisions on the consumer behalf may be a

consumer for the purposes of these standards.

Contractor: A business entity that performs delegated functions on behalf of the Organization.

Interpretive Note for term “Contractor”:

For the purposes of these standards, the term “contractor” includes only those contractors that perform

functions related to the key processes of the Organization. It is not URAC’s intent to include contractors

that provide services unrelated to key processes. For example, a contractor that provides catering

services would not fall within the definition of “contractor” in these standards. Conversely, a company that

provides specialty physician reviewers to a UM organization would clearly fall within the definition of

“contractor.”

Covered Benefits: The specific health services provided under a health benefits program, including:

cost-sharing and other financial features; claims submission and reimbursement processes; requirements

and processes (if any) for prior authorization or other approval of health services.

24
Covered Service: A health care service for which reimbursement or other remuneration is provided to a

consumer or on behalf of a consumer under the terms of the consumer’s benefits program.

Credentials Verification: A process of reviewing and verifying specific credentialing criteria of a

practitioner.

Credentials Verification Organization (CVO): An organization that gathers data and verifies the

credentials of health care practitioners.

Criteria: A broadly applicable set of standards, guidelines, or protocols used by the organization to guide

the clinical processes. Criteria should be:

• Written;

• Based on professional practice;

• Literature-based;

• Applied consistently; and

• Reviewed, at a minimum, annually.

Data Integrity: The quality or condition of being accurate, complete and valid, and not altered or destroyed

in an unauthorized manner. 

Date of Receipt: The date on which a claim arrives at a Organization (or, for claims that arrive on a

non-business day, the date of the first business day thereafter). 

Delegation: The process by which an organization contracts with or otherwise arranges for another entity

to perform functions and to assume responsibilities covered under these standards on behalf of the

organization, while the organization retains final authority to provide oversight to the delegate.

Discharge Planning: The process that assesses a patient’s needs in order to help arrange for the

necessary services and resources to effect an appropriate and timely discharge or transfer from current

services or level of care.

Disease Management (DM): According to the Disease Management Association of America, “Disease

management is a system of coordinated healthcare interventions and communications for populations with

conditions in which patient self-care efforts are significant. Disease management: supports the physician

or practitioner/patient relationship and plan of care, emphasizes prevention of exacerbations and

25
complications utilizing evidence-based practice guidelines and patient empowerment strategies, and

evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving

overall health. Disease management components include: population identification processes;

evidence-based practice guidelines; collaborative practice models to include physician and support-service

providers; patient self-management education (may include primary prevention, behavior modification

programs, and compliance/surveillance); process and outcomes measurement, evaluation, and

management; routine reporting/feedback loop (may include communication with patient, physician, health

plan and ancillary providers, and practice profiling.”

Disease Management Program: A program or entity that provides the scope of functions and activities

necessary to provide disease management.

Electronic: Mode of electronic transmission including the Internet (wide-open), Extranet (using Internet

technology to link a business with information only accessible to collaborating parties), leased lines, dial-up

lines, private networks, and those transmissions that are physically moved from one location to another

using magnetic tape, disk, or compact disk media. (Final Rule, Department of Health and Human

Services, “Health Insurance Reform: Standards for Electronic Transactions,” Federal Register (Aug. 17,

2000).)

Electronic Health Record: An electronic record of health-related information on an individual that

conforms to nationally recognized interoperability standards and that can be created, managed, and

consulted by authorized clinicians and staff across more than one health care organization.

Electronic Medical Record: An electronic record of health-related information on an individual that can be

created, gathered, managed, and consulted by authorized clinicians and staff within one health care

organization.

Engagement: Proactive outbound contact with consumers, by phone or mail, within some specified time

frame of identification of eligible consumers, with tracking of interactions.

Evidence-based: Recommendations based on valid scientific outcomes research, preferably research

that has been published in peer reviewed scientific journals. Evidence-based information can be used to

develop protocols, pathways, standards of care or clinical practice guidelines and related educational

materials.

Evidence Based Medicine: “Evidence based medicine is the conscientious, explicit and judicious use of

current best evidence in making decisions about the care of individual patients.” David L. Sackett, William

26
M. C. Rosenberg, J.A. Muir Gray, R. Brian Haynes, W. Scott Richardson. Evidence based medicine: what

it is and what it isn’t. British Medical Journal 1996; 312:71-72. Reproduced with permission from BMJ

Publishing Group.

Expedited Appeal: An appeal of a non-certification involving imminent or ongoing services.

Facility: An institution that provides health care services.

Facility Rendering Service: The institution or organization in or by which the requested admission,

procedure, or service is provided. Such facilities may include, but are not limited to: hospitals; outpatient

surgical facilities; individual practitioner offices; rehabilitation centers; residential treatment centers; skilled

nursing facilities; laboratories; imaging centers; and other organizational providers of direct services to

patients.

Family: Individuals whom the consumer chooses to involve in the decision-making process regarding the

consumer’s health care. In the case of a consumer who is unable to participate in the decision-making

process, “family” shall include any individual legally authorized to make health care decisions on the

consumer’s behalf.

Health Assessment Tool: A data collection instrument that allows a consumer and the organization to

ascertain the consumer’s health status and health risks. Such tools are often administered online,

although other formats are permissible. Other common terms used to describe health assessment tools

are “health risk assessment” and “health survey.”

Health Benefits Plan: An arrangement to pay for medical services provided to a consumer. “Health

benefits plan” includes (but is not limited to):

• HMOs;

• PPOs;

• Indemnity health insurance programs;

• Self-insured plans;

• Public programs, such as Medicare and Medicaid; and

• Workers’ Compensation insurance programs.

Health Care Team: The attending physician and other health care providers with primary responsibility for

27
the care provided to a consumer.

Health Content Reviewer: An individual who holds a license or certificate as required by the appropriate

jurisdiction in a health care field (where applicable), has professional experience in providing relevant

direct patient care or has completed formal training in a health-related field.

Health Information: Educational resources designed to enhance the knowledge and understanding of

health topics to promote wellness and self-care.

Health Information Exchange: The electronic movement of health-related information among

organizations according to nationally recognized standards.

Health Information Organization: An organization that oversees and governs the exchange of

health-related information among organizations according to nationally recognized standards.

Health Literacy: The degree to which individuals have the capacity to obtain, process, and understand

basic health information and services needed to make appropriate decisions regarding their health.

Health Professional: An individual who: (1) has undergone formal training in a health care field; (2)

holds an associate or higher degree in a health care field, or holds a state license or state certificate in a

health care field; and (3) has professional experience in providing direct patient care.

Health-Related Field: A professional discipline that promotes the physical, psychosocial, or vocational

well being of individual persons.

Individually Identifiable Information: Any information that can be tied to an individual consumer, as

defined by applicable laws.

28
Independent Review: A process, independent of all affected parties, to determine if a health care service

is medically necessary and medically appropriate or experimental/investigational. Independent review

typically (but not always) occurs after all appeals mechanisms available within the health benefits plan

have been exhausted. Independent review can be voluntary or mandated by law.

Interpretive Note for term “Independent Review”: The IRO standards focus on cases regarding

questions of medical necessity/medical appropriateness and whether a treatment is

experimental/investigational. Some independent review programs may also address administrative issues

and disputes. However, these issues are outside the scope of these standards. Therefore, accreditation

under these standards should not be interpreted (or represented) as an endorsement of an organization’s

process for conducting reviews of administrative disputes.

Independent Reviewer: The individual (or individuals) selected by the organization to consider a case. 

Selection of the reviewer(s) for a case must be conducted in accordance with standards IR 1 and IR 6. All

reviewer(s) who are health care practitioners must have the following qualifications:

• Active licensure;

• Recent experience or familiarity with current body of knowledge and medical practice;

• At least 5 years experience providing health care;

If the reviewer is an M.D. or D.O., board certification by a medical specialty board approved by the

American Board of Medical Specialties or the American Osteopathic Association.

• 

• If the reviewer is a D.P.M., board certification by the American Board of Podiatric Surgery.

Initial Clinical Review: Clinical review conducted by appropriate licensed or certified health

professionals. Initial clinical review staff may approve requests for admissions, procedures, and services

that meet clinical review criteria, but must refer requests that do not meet clinical review criteria to peer

clinical review for certification or non-certification. Sometimes referred to as “first level review.”

Interoperability: Ability of two or more systems or components to exchange information and to use the

information that has been exchanged. 

29
Knowledge Domains – Areas of specific expertise.

License: A license or permit (or equivalent) to practice medicine or a health profession that is 1) issued by

any state or jurisdiction in the United States; and 2) required for the performance of job functions.

Interpretive Note for term "License”:

In this definition, the word “equivalent” includes certifications, registrations, permits, etc. Specific terms

will vary by state and health profession.

Medical Director: A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice

medicine and who is an employee of, or party to a contract with, an organization, and who has

responsibility for clinical oversight of the organization’s utilization management, credentialing, quality

management, and other clinical functions.

Medical Management – A general term encompassing activities such as utilization management, case

management, and the clinical aspects of quality management.

Non-Certification: A determination by an organization that an admission, extension of stay, or other

health care or pharmacy service has been reviewed and, based on the information provided does not

meet the clinical requirements for medical necessity, appropriateness, or effectiveness under the

applicable health benefitplan.

Non-Clinical Administrative Staff: Staff who do not meet the definition of health professional (including

intake personnel).

Non-Clinical Staff: Employees or contracted consultants of a health care organization who do not

perform clinical assessments or provide callers with clinical advice. They may be responsible for obtaining

demographic information, providing benefit information, and re-directing callers.

Off-shoring: The relocation of an organizational function to a foreign country under the same

organizational control (ownership).

30
Note related to off-shoring: In health care management, outsourcing distinct functions to a

foreign subcontractor is the more common trend. See the definition for "outsourcing."

Opt-in: Affirmative consent actively provided by a consumer to participate in an activity or function of the

program, provided after the program has fully disclosed the terms and conditions of participation to the

consumer.

Note for term "Opt-in": Auto enrollees are not considered "opt-in" enrollees of the program.

Opt-out: A process by which an enrolled consumer declines to participate in an activity or function of the

program.

Ordering Provider: The physician or other provider who specifically prescribes the health care service

being reviewed.

Organization: A business entity that seeks accreditation under these standards. 

Interpretive Note for term “Organization”: This can include a program or department and can be

geographically defined.

Organizational Conflict of Interest: A conflict that affects objectivity between the organization's financial

interests and the organization's obligations to the client.

Outcome: A consumer’s health status following services.

Outsourcing: The delegation of services or functions from internal production to an external entity outside

of the United States.

Oversight: Monitoring and evaluation of the integrity of relevant program processes and decisions

affecting consumers.

Participant (participating): An eligible consumer or treating provider that has had one or more inbound or

outbound contacts with the disease management program, and if a consumer, has not opted out of the

program.

Participating Provider – A provider that has entered into an agreement with the organization to be part of

a provider network.

31
Patient: The enrollee or covered consumer for whom a request for certification may or may not have been

filed. 

Interpretive Note for term “Patient”: In the case of a patient who is unable to participate in the

decision-making process, a family member or other individual legally authorized to make health care

decisions on the patient’s behalf may be a patient for the purposes of these standards.

Peer Clinical Review: Clinical review conducted by appropriate health professionals when a request for

an admission, procedure, or service was not approved during initial clinical review. Sometimes referred to

as “second level review.”

Peer-to-Peer Conversation: A request by telephone for additional review of a utilization management

determination not to certify, performed by the peer reviewer who reviewed the original decision, based on

submission of additional information or a peer-to-peer discussion.

Personal Health Record: An electronic record of health-related information on an individual that conforms

to nationally recognized interoperability standards and that can be drawn from multiple sources while being

managed, shared, and controlled by the individual.

Personally-identifiable Information: Any information that can be tied to an individual identifier.

Performance Measures: Qualitative or quantitative quality indicators for assessing the achievement of

outcomes. www.wtcc.sa.gov.au/webdata/resources/files/sp_glossary.doc

Plain Language: Communication that uses short words and sentences, common terms instead of

(medical) jargon, and focuses on the essential information recipients need to understand.

Population: Depending on the model of the disease management program, the population for which it is

responsible may be all of the consumers identified with the disease condition, or the population may be

only those consumers identified to the disease management program by client referral or another

mechanism. In some instances the disease management program may be responsible for identification of

the population, and in other instances the client may conduct identification (and stratification) activities.

32
Potential Enrollees: Employees and eligible dependents of employer/purchasers who are offering

enrollment in the organization’s products as part of the employee benefits package. In the case of

organizations that offer products in the individual market, potential enrollees include individuals from the

general public in the geographic area where the organization offers the products.

Practitioner – An individual person who is licensed to deliver health care services without supervision.

Pre-Review Screening: Automated or semi-automated screening of requests for authorization that may

include: (1) collection of structured clinical data (including diagnosis, diagnosis codes, procedures,

procedure codes); (2) asking scripted clinical questions; (3) accepting responses to scripted clinical

questions; and (4) taking specific action (certification and assignment of length of stay explicitly linked to

each of the possible responses). It excludes: (1) applying clinical judgment or interpretation; (2) accepting

unstructured clinical information; (3) deviating from script; (4) engaging in unscripted clinical dialogue; (5)

asking clinical follow-up questions; and (6) issuing non-certifications.

Primary Physician: The physician who is primarily responsible for the medical treatment and services of

a consumer.

Primary Source Verification: Verification of a practitioner’s credentials based upon evidence obtained

from the issuing source of the credential. Also known as "Primary Source."

Principal Reason(s): A clinical or non-clinical statement describing the general reason(s) for the

non-certification determination (“lack of medical necessity” is not sufficient to meet this).

Professional Competency: The ability to perform assigned professional responsibilities.

Prospective Review: Utilization management conducted prior to a patient’s admission, stay, or other

service or course of treatment (including outpatient procedures and services). Sometimes called

“precertification review” or “prior authorization.”

Protected Health Information: Individually identifiable health information: (1) Except as provided in

paragraph (2) of this definition, that is: (i) Transmitted by electronic media; (ii) Maintained in any medium

described in the definition of electronic media at Sec. 162.103 of this subchapter; or (iii) Transmitted or

maintained in any other form or medium. (2) Protected health information excludes individually identifiable

33
health information in: (i) Education records covered by the Family Educational Rights and Privacy Act, as

amended, 20 U.S.C. 1232g; (ii) Records described at 20 U.S.C. 1232g(a)(4)(B)(iv); and (iii) Employment

records held by a covered entity in its role as employer. (67 Fed. Reg. at 53,267 (Aug. 14, 2002); 65 Fed.

Reg. at 82,805 (Dec. 28, 2000) (to be codified at 45 C.F.R. pt. 164.501)).

Provider: A licensed health care facility, program, agency, or health professional that delivers health care

services.

Provider Network – A group of providers with which the organization contracts to provide health services

to consumers.

Provider-Specific Information: Information that is sufficient to allow identification of the individual

provider.

Quality Improvement Project: An organization-wide initiative to measure and improve the service and/or

care provided by the organization.

Quality Management (QM) program: A systematic data-driven effort to measure and improve consumer

and client services and/or health care services.

Quality Review Study: A scientific and systematic measurement of the effects or results of treatment

modalities or practices for a particular disease or condition. The goal of quality measurement is to improve

health care services by monitoring and analyzing the data and modifying practices in response to this data.

Rationale: The reason(s) or justification(s) – commonly based on criteria – for a specific action or

recommendation.

Re-assessment: Re-evaluation of an individual participating in the disease management program on a

specified frequency, using the same or similar tools that were used in the initial assessment. 

Re-assessment may also include re-stratification. 

Referring Entity: The organization or individual that refers a case to an organization. Referring entities

may include insurance regulators, health benefits plans, consumers, and attending providers. Some states

may limit by law which individuals or organizations may be a referring entity.

Regional Health Information Organization: A health information organization that brings together health

care stakeholders within a defined geographic area and governs health information exchange among them

for the purpose of improving health and care in that community.

Retrospective Claim: A claim presented after services have been provided (i.e., a post-service claim)

and presented for consideration under a contract or policy.

34
Retrospective Review: Review conducted after services (including outpatient procedures and services)

have been provided to the patient. 

Interpretive Note for term “Retrospective Review”: Retrospective medical necessity determinations

are considered utilization management (and subject to these standards).

Review of Service Request: Review of information submitted to the organization for health care services

that do not need medical necessity certification nor result in a non-certification decision.

Reviewer(s): The individual (or individuals) selected by the organization to consider a case. Selection of

the reviewer(s) for a case must be conducted in accordance with standards IR 1 and IR 6. All reviewer(s)

who are health care practitioners must have the following qualifications:

• Active licensure;

• Recent experience or familiarity with current body of knowledge and medical practice;

• At least 5 years experience providing health care;

If the reviewer is an M.D. or D.O., board certification by a medical specialty board approved by the

American Board of Medical Specialties or the American Osteopathic Association.

• 

• If the reviewer is a D.P.M., board certification by the American Board of Podiatric Surgery

Second Opinion: Requirement of some health plans to obtain an opinion about the medical necessity and

appropriateness of specified proposed services by a practitioner other than the one originally making the

recommendation.

Secondary Source Verification or Secondary Source: Verification of a practitioner’s credentials based

upon evidence obtained by means other than direct contact with the issuing source of the credential (e.g.,

copies of licenses and certifications and data base queries).

Service Requests: Screening callers to determine the services that are necessary at the time of the call. 

This is usually performed by a non-clinical staff person to determine if the call is clinical and requires

transfer to a clinical staff person.

Staff: The Organization’s employees, including full-time employees, part-time employees, and consultants.

Standard Appeal: An appeal of a non-certification that is not an expedited appeal. In most cases,

standard appeals will not relate to cases involving urgent care. However, standard appeals may also

include secondary appeals of expedited appeals.

Statistically valid: Based on accepted statistical principles and techniques.

Stratification: A process for sorting a population of eligible consumers into groups relating to the need for

disease management interventions. Stratification and assessment are inter-related, and both provide data

35
used to assign interventions. Stratification may use a variety of data sources, including but not limited to

claims, pharmacy, laboratory, or consumer-reported data. 

Structured Clinical Data: Clinical information that is precise and permits exact matching against explicit

medical terms, diagnoses or procedure codes, or other explicit choices, without the need for interpretation.

Therapeutic: Of or relating to the treatment of disease or disorders by remedial agents or methods.

Treating Provider: The treating provider is the individual or provider group who is primarily managing the

treatment for a consumer participant in the disease management program. The treating provider is not

necessarily the consumers’ primary care physician. The consumer may have a different treating provider

for different conditions.

Utilization Management (UM): Evaluation of the medical necessity, appropriateness, and efficiency of use

of health care services, procedures, and facilities. UM encompasses prospective, concurrent and

retrospective review in which clinical criteria are applied to a request. UM is sometimes called "utilization

review".

Worker: An ill or injured individual (or representative acting on behalf of the worker) who is eligible for

workers’ compensation benefits and who files for, or for whom a workers’ compensation claim has been

filed.

Written Agreements: A document – including an electronic document – that specifies the terms of a

relationship between the Organization and a client, consumer, or contractor. This term may include a

contract and any attachments or addenda. 

Written Notification: Correspondence transmitted by mail, facsimile, or electronic medium.

Individually identifiable health information is information that is a subset of health information, including

demographic information collected from an individual, and: (1) Is created or received by a health care

provider, health plan, employer, or health care clearinghouse; and (2) Relates to the past, present, or

future physical or mental health or condition of an individual; the provision of health care to an individual; or

the past, present, or future payment for the provision of health care to an individual; and (i) That identifies

the individual; or (ii) With respect to which there is a reasonable basis to believe the information can be

used to identify the individual. (65 Fed. Reg. at 82,804 (to be codified at 45 C.F.R. pt. 164.501))

 (Note: This definition is derived from the federal Health Insurance Portability and Accountability Act

(HIPAA)).

36
37
38
Crosswalk between Core v2.1 & v3.0

Crosswalk between Core v2.1 & v3.0

std # std # std # std #

version version version version

3.0 2.1 Notes 2.1 3.0 Notes

1 1 1 1

2 2 2 2

3 3 3 3

4 19 4 25

5 12 5 26

6 15 6 30

7 16 7 27

8 17 8 28

9 18 9 29

10 21 Old 21(a), (c) & (d) in

new Core 10 10 31

11 14 11 32

12 24 Client satisfaction

brought from Core 24 12 5

13 13(a) & (d) New: Interoperability

[Leading Indicator] 13 13, 14 & 15

14 Core 13(c) Comes from Core

13(c) in v2.1 14 11

15 Core 13(b) Comes from Core

13(b) in v2.1 15 6

16 23 16 7

17 29 17 8

18 30 18 9

19 31 19 4

20 32 20 33

21 33 21 10 & 34

22 Core 35

(stem)

Comes from stem of

Core 35 in v2.1 22 38

23 34 23 16

24 35 24 39 Consumer

Satisfaction

25 4 25 34

39
26 5 26 35

27 7 27 35

28 8 28 35

29 9 29 17

30 6 30 18

31 10 31 19

32 11 32 20

33 20 33 21

34 25 34 23

35 26, 27 &

28 35 24

36 new std External Coordination --- 36

37 Core 21(e) Comes from Core

21(e) in v2.1 --- 40

38 22

39 24 Consumer satisfaction

40 new std Health Literacy

40
41
Core v3.0 Consumer-Facing Accreditations

Consumer-Facing Accreditations

Core v3.0

Core standards apply to

all accreditations unless

determined to be N/A

ALL HEALTH

ACCREDITATIONS

(that include Core)

Core standards apply if

accreditation requires an

organization to have

credentialed clinical staff

MUST HAVE

LICENSED/CERTIFIED

CLINICAL STAFF

Core standards apply if

accreditation requires an

organization to have

clinical staff that

interfaces with

consumers on an

ongoing basis to provide

health care management

support services directly

to the consumer

CONSUMER-FACING

Health

Accreditation

Products

that Include

Core

Core 1-23

& 25-29 Core 30-35 Core 24 (safety QIP)& Core 36-40

Core

(stand-alone) x ?

1 ?1

Case

Management x x x

Disease

Management x x x

Health Call

Center x x x

Health Plan x x x

Consumer

Education &

Support

x x x

Heatlh

Utilization

Management

x x

Workers'

Compensation

UM

x x

Independent

Review

x x

42
Organization

Health

Network x x

Provider

Credentialing x x

Claims

Processing x x

Credentials

Verification

Organization

x

x - if conducting physician

office reviews (CVO 11)

1For Core stand-alone accreditation applicants, Core 30-35, 24 & 36-40 may

or may not apply depending upon the type of business covered by the

accreditation. URAC staff will work with these applicants to determine

which standards are applicable and which ones are not.

43
44
Applicability of Core Organizational Quality Standards,

Version 3.0

Applicability of Core Organizational Quality Standards, version 3.0

For the URAC Core Organizational Quality Standards version 3.0 (Core), the standards have been reorganized to

ease the application process. Standards listed first apply to all health care organizations. These standards are followed

by those where the applicant organization must have credentialed licensed or certified clinical staff in order to

conduct the function covered by the accreditation. The last sections of Core apply to those organizations that interact

directly with health care consumers on an ongoing basis in order to provide health care management support services

directly to the consumer. This was done to address the fact that many of the organizations which URAC accredits

under the Core standards do not interact directly with consumers, but instead are business partners or vendors to

organizations that do.

The following sections of standards address infrastructure and human resources and are applicable to all

organizations applying for accreditation or certification including stand-alone Core applicants, though some standards

may be determined to be not applicable. For example, the delegation standards would not apply if an organization

does not delegate.

· Organizational Structure

· Policies and Procedures

· Regulatory Compliance

· Inter-Departmental Coordination

· Oversight of Delegated Functions

· Marketing and Sales Communications

· Business Relationships

· Information Management

· Quality Management

· Staff Qualifications

· Staff Management

The Clinical Staff Credentialing and Oversight Role section covers clinical oversight and are applicable to

organizations applying for accreditations that require licensed or certified clinical staff in order to perform the

function covered by the accreditation. These standards may not apply to certain stand-alone Core applicants. 

45
Lastly, the Core sections on Health Care System Coordination and Consumer Protection and Empowerment are

applicable to organizations that are involved with care coordination and interact with consumers. These accreditation

products cover functions that require an organization to interact with consumers on an ongoing basis in order to

provide health care management services directly to the consumer.

The table below is color coded to show which standards are applicable under the

various types of URAC accreditation products.

Blue: Standards apply regardless of accreditation, though it may be determined that some standards are not

applicable (“N/A”) for a given organization.

Purple: Standards are applicable if the accreditation requires an organization to have licensed or certified clinical

staff. (Note that these standards may or may not apply to an organization applying only for Core accreditation.)

Black: Standards are applicable for accreditations that require an organization to have licensed or certified clinical

staff that interfaces with consumers on an ongoing basis in order to provide health care management support services

directly to the consumer. (Note that these standards may or may not apply to an organization applying only for Core

accreditation.)

Core Organizational Quality Standards, version 3.0

· Organizational Structure

1-Organizational Structure

2-Organization Documents

· Policies and Procedures

3-Policy and Procedure Maintenance, Review and

Approval

· Regulatory Compliance

4-Regulatory Compliance

· Inter-Departmental Coordination

5-Inter-Departmental Coordination

· Oversight of Delegated Functions

6-Delegation Review Criteria

7-Delegation Review

8-Delegation Contracts

9-Delegation Oversight

· Marketing and Sales

Communications

· Quality Management

17-Quality Management Program

18-Quality Management Program Resources

19-Quality Management Program Requirements

20-Quality Management Committee

21-Quality Management Documentation

22-Quality Improvement Projects

23-Quality Improvement Project Requirements

24-Quality Improvement Projects:

Consumer Organizations

· Staff Qualifications

25-Job Descriptions

26-Staff Qualifications

· Staff Management

27-Staff Training Program

28-Staff Operational Tools and Support

29-Staff Assessment Program

46
10-Review of Marketing and Sales Materials

· Business Relationships

11-Written Business Agreements

12-Client Satisfaction

· Information Management

13-Information Management

14-Business Continuity

15-Information Confidentiality and Security

16-Confidentiality of Individually-Identifiable

 Health Information

· Clinical Staff Credentialing and

Oversight Role

30-Clinical Staff Credentialing

31-Senior Clinical Staff Requirements

32-Senior Clinical Staff Responsibilities

33-Financial Incentive Policy

34-Access to Services

35-Consumer Complaint Process

· Health Care System Coordination

36-Coordination with External Entities

· Consumer Protection and

Empowerment

37-Consumer Rights and Responsibilities

38-Consumer Safety Mechanism

39-Consumer Satisfaction

40-Health Literacy

47
48
CORE, Version 3.0

Organizational Structure

CORE - 1 - Organizational Structure

The organization has a clearly defined organizational structure outlining direct and indirect oversight

responsibility throughout the organization. (2)

CORE - 2 - Organization Documents

Organization’s documents address: (No Weight)

(a) Mission statement; (2)

(b) Organizational framework for program; (2)

(c) The population served; and (2)

(d) Organizational oversight and reporting requirements of the program. (2)

Policies and Procedures

CORE - 3 - Policy and Procedure Maintenance, Review, and Approval

The organization: (No Weight)

(a) Maintains and complies with written policies and documented procedures that govern core

business processes of its operations related to the scope of the accreditation; (Mandatory)

(b) Maintains the ability to produce a master list of all such policies and procedures; (2)

(c) Reviews written policies and documented procedures no less than annually and revises as

necessary; (3)

(d) Includes the following on the master list or on all written policies and documented

procedures: (No Weight)

(i) Effective dates, review dates, including the date of the most recent revision;

and (2)

49
(ii) Identification of approval authority. (2)

Regulatory Compliance

CORE - 4 - Regulatory Compliance

The organization implements a regulatory compliance program that: (No Weight)

(a) Tracks applicable laws and regulations in the jurisdictions where the organization conducts

business; (Mandatory)

(b) Ensures the organization's compliance with applicable laws and regulations; and (Mandatory)

(c) Responds promptly to detected problems and takes corrective action as needed. (4)

Inter-Departmental Coordination

CORE - 5 - Inter-Departmental Coordination

The organization establishes and implements mechanisms to promote collaboration, coordination and

communication across disciplines and departments within the organization, with emphasis on integrating

administrative activities, quality improvement, and where present, clinical operations. (3)

Oversight of Delegated Functions

CORE - 6 - Delegation Review Criteria

The organization establishes and implements criteria and processes for an assessment prior to the delegation of

functions. (3)

CORE - 7 - Delegation Review

Prior to delegating functions to another entity, the organization: (No Weight)

(a) Establishes and implements a process to conduct a review of the potential contractor’s written

policies and documented procedures and capacity to perform delegated functions; and (3)

(b) Outlines and follows criteria and processes for approving contractors. (3)

50
CORE - 8 - Delegation Contracts

The organization enters into written agreements with contractors that: (No Weight)

(a) Specify those responsibilities delegated to the contractor and those retained by the

organization; (2)

(b) Require that services be performed in accordance with the organization's requirements and

URAC standards; (Mandatory)

(c) Require notification to the organization of any material change in the contractor’s ability to

perform delegated functions; (4)

(d) Specify that the organization may conduct surveys of the contractor, as needed; (2)

(e) Require that the contractor submit periodic reports to the organization regarding the

performance of its delegated responsibilities; (3)

(f) Specify recourse and/or sanctions if the contractor does not make corrections to identified

problems within a specified period; (2)

(g) Specify the circumstances under which activities may be further delegated by the contractor,

including any requirements for obtaining permission from the organization before any further

delegation; and (4)

(h) Specify that, if the contractor further delegates organizational functions, those functions shall

be subject to the terms of the written agreement between the contractor and the organization and

in accordance with URAC standards. (Mandatory)

CORE - 9 - Delegation Oversight

The organization establishes and implements an oversight mechanism for delegated functions within

the scope of accreditation that includes: (No Weight)

(a) A periodic review (no less than annually) of the contractor's written policies and documented

procedures and documentation of quality activities for related delegated functions; (2)

(b) A process to verify (no less than annually) the contractor's compliance with contractual

requirements and written policies and documented procedures; and

(Mandatory)

51
(c) A mechanism to monitor financial incentives to ensure that quality of care or service is not

compromised. (3)

Marketing and Sales Communications

CORE - 10 - Review of Marketing and Sales Materials

The organization follows marketing and sales practices that include: (No Weight)

(a) Mechanisms to clearly and accurately communicate information about services inclusive of

delegated activities; (3)

(b) A formal process of inter-departmental review of marketing and sales materials before

dissemination to safeguard against misrepresentations about the organization's services; (3)

(c) Monitoring of existing materials for accuracy; and (3)

(d) Responds promptly to detected problems and corrective action as needed. (4)

Business Relationships

CORE - 11 - Written Business Agreements

The organization maintains signed written agreements with all clients describing the scope of the business

arrangement. (2)

CORE - 12 - Client Satisfaction

The organization implements a mechanism to collect or obtain information about client satisfaction with services

provided by the organization. (3)

Information Management

CORE - 13 - Information Management

The organization implements information system(s) (electronic and paper) to collect, maintain and analyze

information necessary for organizational management that: (No Weight)

(a) Provides for data integrity; (Mandatory)

52
(b) Includes a plan for storage, maintenance and destruction; and (2)

(c) Includes a plan for interoperability: (No Weight)

(i) Between internal information systems; and (Leading Indicator)

(ii) With external entity information systems. (Leading Indicator)

CORE - 14 - Business Continuity

The organization implements a business continuity plan for program operations, including information system(s)

(electronic and paper) that: (No Weight)

(a) Identifies which systems and processes must be maintained and the effect an outage would

have on the organization's program; (3)

(b) Identifies how business continuity is maintained given various lengths of time information

systems are not functioning or accessible; (3)

(c) Is tested at least every two years; and (3)

(d) Responds promptly to detected problems and takes corrective action as needed. (3)

CORE - 15 - Information Confidentiality and Security

The organization provides for data confidentiality and security of its information system(s) (electronic and paper)

by implementing written policies and/or documented procedures that address: (No Weight)

(a) Assessment of the potential risks and vulnerabilities to the confidentiality, integrity and

availability of information systems; (3)

(b) Prevention of confidentiality and security breaches; and (Mandatory)

(c) Detection, containment and correction of confidentiality and security violations. (Mandatory)

CORE - 16 - Confidentiality of Individually-Identifiable Health Information

The organization implements written policies and/or documented procedures to protect the confidentiality of

individually-identifiable health information that:

(No Weight)

53
(a) Identifies how individually-identifiable health information will be used; (Mandatory)

(b) Specifies that individually-identifiable health information is used only for purposes necessary

for conducting the business of the organization, including evaluation activities; (Mandatory)

(c) Addresses who will have access to individually-identifiable health information collected by the

organization; (Mandatory)

(d) Addresses oral, written or electronic communication and records that are transmitted or stored;

(Mandatory)

(e) Address the responsibility of organization employees, committee members and board

members to preserve the confidentiality of individually-identifiable health information; and

(Mandatory)

(f) Requires employees, committee members and board members of the organization to sign a

statement that they understand their responsibility to preserve confidentiality. (Mandatory)

Quality Management

CORE - 17 - Quality Management Program

The organization maintains a quality management program that promotes objective and systematic measurement,

monitoring and evaluation of services and implements quality improvement activities based upon the findings.

(Mandatory)

CORE - 18 - Quality Management Program Resources

The organization employs staff and/or provides the resources necessary to support the day-to-day operations of the

quality management program. (3)

CORE - 19 - Quality Management Program Requirements

The organization has a written description for its quality management program that: (No Weight)

(a) Is approved by the organization’s appropriate oversight authority; (2)

(b) Defines the scope, objectives, activities, and structure of the quality management program; (2)

(c) Is reviewed and updated by the Quality Management Committee at least annually; (2)

54
(d) Defines the roles and responsibilities of the Quality Management Committee; and (2)

(e) Designates a member of senior management with the authority and responsibility for the

overall operation of the quality management program and who serves on the Quality Management

Committee. (3)

CORE - 20 - Quality Management Committee

The organization has a quality management committee that: (No Weight)

(a) Is granted authority for quality management by the organization's oversight authority; (3)

(b) Provides ongoing reporting to the organization's oversight authority; (3)

(c) Meets at least quarterly; (3)

(d) Maintains approved records of all committee meetings; (2)

(e) If applicable, includes at least one participating provider or receives input from participating

providers; (4)

(f) Provides guidance to staff on quality management priorities and projects; (3)

(g) Approves the quality improvement projects to undertake; (3)

(h) Monitors progress in meeting quality improvement goals; and (3)

(i) Evaluates the effectiveness of the quality management program at least annually. (3)

CORE - 21 - Quality Management Documentation

The organization, as part of its quality management program, provides written documentation of: (No Weight)

(a) Objectives and approaches utilized in the quality management activities; (3)

(b) Identification and tracking and trending of performance measures relevant to the scope of the

accreditation including, but not limited to: (Mandatory)

(i) Access to services; (3)

55
(ii) Complaints; and (3)

(iii) Satisfaction; (3)

(c) Measures that are quantifiable and used to establish acceptable levels of performance;

(Mandatory)

(d) Measuring baseline level of performance; (Mandatory)

(e) Re-measuring level of performance at least annually; (Mandatory)

(f) The implementation of action plans to improve or correct identified problems or meet

acceptable levels of performance on measures; (Mandatory)

(g) The mechanisms to communicate the results of such activities to relevant staff; and (3)

(h) The mechanism to communicate the results of such activities to the quality management

committee. (3)

CORE - 22 - Quality Improvement Projects

At any given time, the organization maintains no less than two quality improvement projects that address

opportunities for error reduction or performance improvement related to the services covered by the accreditation.

(Mandatory)

CORE - 23 - Quality Improvement Project Requirements

For each quality improvement project, the organization will:

(No Weight)

(a) Establish measurable goals for quality improvement; (3)

(b) Design and implement strategies to improve performance; (3)

(c) Establish projected time frames for meeting goals for quality improvement; (3)

(d) Re-measure level of performance at least annually; (3)

(e) Document changes or improvements relative to the baseline measurement; and (3)

56
(f) Conduct an analysis if the performance goals are not met. (3)

CORE - 24 - Quality Improvement Projects: Consumer Organizations

For an organization that interacts with consumers: (No Weight)

(a) At least one of the two quality improvement projects must address consumer safety for the

population served; and (Mandatory)

(b) If the quality improvement project is clinical in nature, then the organization demonstrates the

involvement of a senior clinical staff person in judgments about the use of clinical quality

measures and clinical aspects of performance. (Mandatory)

Staff Qualifications

CORE - 25 - Job Descriptions

The organization has written job descriptions for staff that address requirements pertinent to the scope of the

positions' roles and responsibilities: (No Weight)

(a) Required education, training, and/or professional experience; (2)

(b) Expected professional competencies; (2)

(c) Appropriate licensure/certification requirements; and (2)

(d) Current scope of roles and responsibilities. (2)

CORE - 26 - Staff Qualifications

Staff meets qualifications as required in written job descriptions. (3)

Staff Management

CORE - 27 - Staff Training Program

The organization has an ongoing training program that includes: (No Weight)

57
(a) Initial orientation and/or training for all staff before assuming assigned roles and

responsibilities; (2)

(b) Training in current URAC standards as appropriate to job functions; (2)

(c) Conflict of interest; (4)

(d) Confidentiality; (Mandatory)

(e) Documentation of all training provided for staff; and (2)

(f) Ongoing training, at a minimum annually, to maintain professional competency. (2)

CORE - 28 - Staff Operational Tools and Support

The organization provides staff with: (No Weight)

(a) Written policies and/or documented procedures appropriate to their jobs; (2)

(b) Clinical decision support tools as appropriate; and (2)

(c) Regulatory requirements as related to their job function. (2)

CORE - 29 - Staff Assessment Program

The organization maintains a formal assessment program for individual staff members, which includes: (No

Weight)

(a) An annual performance appraisal; and (2)

(b) A review of relevant documentation produced by that individual staff member. (3)

Clinical Staff Credentialing and Oversight Role

CORE - 30 - Clinical Staff Credentialing

The organization implements a written policy and/or documented procedure to: (No Weight)

(a) Primary source verify the current licensure or certification of staff whose job description

requires licensure or certification upon hire, and thereafter no less than every three (3) years;

58
(Mandatory)

(b) Require staff to notify the organization in a timely manner of an adverse change in licensure

or certification status; (Mandatory)

(c) Implement corrective action in response to adverse changes in licensure or certification status;

and (Mandatory)

(d) Primary source verify current licensure and certification upon hire, and thereafter no later

than scheduled expiration. (Leading Indicator)

CORE - 31 - Senior Clinical Staff Requirements

The organization designates at least one senior clinical staff person who has: (No Weight)

(a) Current, unrestricted clinical license(s) (or if the license is restricted, the organization has a

process to ensure job functions do not violate the restrictions imposed by the state licensure

board); (Mandatory)

(b) Qualifications to perform clinical oversight for the services provided; (Mandatory)

(c) Post-graduate experience in direct patient care; and (Mandatory)

(d) Board certification (if the senior clinical staff person is an M.D. or D.O.). (3)

CORE - 32 - Senior Clinical Staff Responsibilities

A senior clinical staff person's program responsibilities include: (No Weight)

(a) Provides guidance for clinical operational aspects of the program; (3)

(b) Is responsible for oversight of clinical decision-making aspects of the program; (Mandatory)

(c) Has periodic consultation with practitioners in the field; and (3)

(d) Ensures the organizational objective to have qualified clinicians accountable to the

organization for decisions affecting consumers. (Mandatory)

59
CORE - 33 - Financial Incentive Policy

If the organization has a system for reimbursement, bonuses or incentives to staff or health care providers based

directly on consumer utilization of health care services, then the organization implements mechanisms addressing

how the organization will ensure that consumer health care is not compromised. (Mandatory)

CORE - 34 - Access to Services

The organization implements written policies and/or documented procedures to ensure access to services covered

by the accreditation. (Mandatory)

CORE - 35 - Consumer Complaint Process

The organization maintains a formal process to address consumer complaints that includes: (No Weight)

(a) A process to receive and respond in a timely manner to complaints; (Mandatory)

(b) Notice (written or verbal) of final result with an explanation; (4)

(c) Informs consumers of the avenues to seek further review if an additional complaint review

process is available; (4)

(d) Evidence of meeting the organization's specified time frame for resolution and response; and

(4)

(e) Reporting analysis of the complaints to the quality management committee. (3)

Health Care System Coordination

CORE - 36 - Coordination with External Entities

The organization establishes and implements mechanisms to promote collaboration and communication with

applicable external entities to coordinate health services for consumers. (1)

Consumer Protection and Empowerment

60
CORE - 37 - Consumer Rights and Responsibilities

The organization implements a mechanism for informing consumers of their rights and responsibilities. (4)

CORE - 38 - Consumer Safety Mechanism

The organization has a mechanism to respond on an urgent basis to situations that pose an immediate threat to the

health and safety of consumers. (Mandatory)

CORE - 39 - Consumer Satisfaction

The organization implements a mechanism to collect or obtain information about consumer satisfaction with

services provided by the organization. (3)

CORE - 40 - Health Literacy

The organization will implement written policies and/or documented procedures addressing health literacy that:

(No Weight)

(a) Require consumer materials to be in plain language; (Leading Indicator)

(b) Assess the use of plain language in consumer documents; and (Leading Indicator)

(c) Provide relevant information and guidance to staff that interfaces directly with, or writes

content for, consumers. (Leading Indicator)

61
Health Utilization Management , Version 6.0

Review Criteria

HUM - 1 - Review Criteria Requirements

The organization utilizes explicit clinical review criteria or scripts that are: (No Weight)

(a) Developed with involvement from appropriate providers with current knowledge relevant to

the criteria or scripts under review; (3)

(b) Based on current clinical principles and processes; (3)

(c) Evaluated at least annually and updated if necessary by: (3)

(i) The organization itself; and (3)

(ii) Appropriate, actively practicing physicians and other providers with current

knowledge relevant to the criteria or scripts under review; and (Mandatory)

(d) Approved by the medical director (or equivalent designate) or clinical director (or equivalent

designate). (Mandatory)

Accessibility of Review Services

HUM - 2 - Access to Review Staff

The organization provides access to its review staff by a toll free or collect telephone line at a minimum from 9:00

a.m. to 4:00 p.m. of each normal business day in each time zone where the organization conducts at least two

percent of its review activities. (4)

HUM - 3 - Review Service Communication and Timeframes

The organization maintains processes to: (No Weight)

(a) Receive communications from providers and patients during the business day and after

business hours; (4)

(b) Respond to communications within one business day; and (4)

62
(c) Conduct its outgoing communications related to utilization management during providers'

reasonable and normal business hours, unless otherwise mutually agreed. (4)

HUM - 4 - Review Service Disclosures

The organization: (No Weight)

(a) Requires utilization management staff to identify themselves by name, title, and organization

name; and (2)

(b) Upon request, verbally informs patients; facility personnel; the attending physician and other

ordering providers; and health professionals of specific utilization management requirements and

procedures. (4)

On-Site Review Services

HUM - 5 - Onsite Review Requirements

For on-site review services, the organization: (No Weight)

(a) Requires on-site reviewers to carry a picture ID with full name and the name of the

organization; (2)

(b) Schedules reviews at least one business day in advance, unless otherwise agreed; and (4)

(c) Requires the on-site reviewers to follow reasonable hospital or facility procedures, including

checking in with designated hospital or facility personnel. (4)

HUM - 6 - N/A

This standard number is reserved to synchronize with URAC's Workers' Compensation Utilization

Management Standards. There is no current Standard UM 6. (No Weight)

Initial Screening

63
HUM - 7 - Limitations in Use of Non-Clinical Staff

For initial screening, the organization limits use of non-clinical administrative staff to: (No Weight)

(a) Performance of review of service request for completeness of information; (2)

(b) Collection and transfer of non-clinical data; (2)

(c) Acquisition of structured clinical data; and (2)

(d) Activities that do not require evaluation or interpretation of clinical information. (Mandatory)

HUM - 8 - Pre-Review Screening Staff Oversight

The organization ensures that licensed health professionals are available to non-clinical administrative staff while

performing initial screening. (Mandatory)

HUM - 9 - Pre-Review Screening Non-Certifications

The organization does not issue non-certifications based on initial screening. (Mandatory)

Initial Clinical Review

HUM - 10 - Initial Clinical Reviewer Qualifications

Individuals who conduct initial clinical review: (No Weight)

(a) Are appropriate health professionals; and (Mandatory)

(b) Possess an active professional relevant license. (Mandatory)

HUM - 11 - Initial Clinical Reviewer Resources

Individuals who conduct initial clinical review have access to consultation with a: (3)

(a) Licensed doctor of medicine or doctor of osteopathic medicine; or (No Weight)

(b) Licensed health professional in the same licensure category as the ordering provider; or (No

Weight)

64
(c) Health professional with the same clinical education as the ordering provider in clinical

specialties where licensure is not issued. (No Weight)

HUM - 12 - Initial Clinical Reviewer Non-Certifications

The organization does not issue non-certifications based on initial clinical review. (Mandatory)

Peer Clinical Review

HUM - 13 - Peer Clinical Review Cases

The organization conducts peer clinical reviews for all cases where a certification is not issued through initial

clinical review or initial screening. (Mandatory)

HUM - 14 - Peer Clinical Reviewer Qualifications

Individuals who conduct peer clinical review: (No Weight)

(a) Are appropriate health professionals; (Mandatory)

(b) Are qualified, as determined by the medical director or clinical director, to render a clinical

opinion about the medical condition, procedures, and treatment under review; and (Mandatory)

(c) Hold a current and valid license: (Mandatory)

(i) In the same licensure category as the ordering provider; or (No Weight)

(ii) As a doctor of medicine or doctor of osteopathic medicine. (No Weight)

Peer-to-Peer Conversation

HUM - 15 - Peer-to-Peer Conversation Availability

Health professionals that conduct peer clinical review are available to discuss review determinations with

attending physicians or other ordering providers. (4)

65
HUM - 16 - Peer-to-Peer Conversation Alternate

When a determination is made to issue a non-certification and no peer-to-peer conversation has occurred: (No

Weight)

(a) The organization provides, within one business day of a request by the attending physician or

ordering provider, the opportunity to discuss the non-certification decision: (No Weight)

(i) With the clinical peer reviewer making the initial determination; or (4)

(ii) With a different clinical peer, if the original clinical peer reviewer cannot be

available within one business day); and (4)

(b) If a peer-to-peer conversation or review of additional information does not result in a

certification, the organization informs the provider and consumer of the right to initiate an appeal

and the procedure to do so. (4)

Time Frames for Initial UM Decision

HUM - 17 - Prospective Review Timeframes

For prospective review, the organization issues a determination: (No Weight)

(a) As soon as possible based on the clinical situation, but in no case later than 72 hours of the

receipt of request for a utilization management determination, if it is a case involving urgent care;

or (4)

(b) Within 15 calendar days of the receipt of request for a utilization management determination,

if it is a non-urgent case. (4)

(c) For non-urgent cases this period may be extended one time by the organization for up to 15

calendar days: (No Weight)

(i) Provided that the organization determines that an extension is necessary

because of matters beyond the control of the organization; and (4)

(ii) Notifies the patient, prior to the expiration of the initial 15 calendar day

period of the circumstances requiring the extension and the date when the plan

expects to make a decision; and (4)

66
(iii) If a patient fails to submit necessary information to decide the case, the

notice of extension must specifically describe the required information, and the

patient must be given at least 45 calendar days from receipt of notice to respond

to the plan request for more information. (4)

HUM - 18 - Retrospective Review Timeframes

For retrospective review, the organization issues a determination: (No Weight)

(a) Within 30 calendar days of the receipt of request for a utilization management determination;

and (3)

(b) This period may be extended one time by the organization for up to 15 calendar days: (No

Weight)

(i) Provided that the organization determines that an extension is necessary

because of matters beyond the control of the organization; and (4)

(ii) Notifies the patient, prior to the expiration of the initial 30 calendar day

period of the circumstances requiring the extension and the date when the plan

expects to make a decision; and (4)

(iii) If a patient fails to submit necessary information to decide the case, the

notice of extension must specifically describe the required information, and the

patient must be given at least 45 calendar days from receipt of notice to respond

to the plan request for more information. (4)

HUM - 19 - Concurrent Review Timeframes

For concurrent review, the organization adheres to the following time frames: (No Weight)

(a) For reductions or terminations in a previously approved course of treatment, the organization

issues the determination early enough to allow the patient to request a review and receive a

decision before the reduction or termination occurs; and (4)

(b) For requests to extend a current course of treatment, the organization issues the determination

within: (No Weight)

(i) 24 hours of the request for a utilization management determination, if it is a

case involving urgent care and the request for extension was received at least 24

67
hours before the expiration of the currently certified period or treatments; or (4)

(ii) 72 hours of the request for a utilization management determination, if it is a

case involving urgent care and the request for extension was received less than 24

hours before the expiration of the currently certified period or treatments. (4)

Notice of Certification Decisions

HUM - 20 - Certification Decision Notice and Tracking

For certifications, the organization: (No Weight)

(a) Has a process for notification of the attending physician or other ordering provider, facility

rendering service, and patient: (4)

(b) Includes tracking information (such as reference number) in the notice of certification; and (3)

(c) Upon request from the attending physician or other ordering provider, facility rendering

service, or patient, provides written notification of any certification. (4)

HUM - 21 - Continued Certfication Decision Requirements

Confirmation of certification for continued hospitalization or services includes the number of extended days or

units of service, the next anticipated review point, the new total number of days or services approved, and the date

of admission or onset of services. (3)

Notice of Non-Certification Decisions

HUM - 22 - Written Notice of Non-Certification Decisions and Rationale

For non-certifications, the organization issues written notification of the non-certification decision to the patient

and attending physician or other ordering provider or facility rendering service that includes: (No Weight)

(a) The principle reasons for the determination not to certify; (4)

(b) A statement that the clinical rationale used in making the non-certification decision will be

provided, in writing, upon request; and (4)

(c) Instructions for: (No Weight)

68
(i) Initiating an appeal of the non-certification; and (Mandatory)

(ii) Requesting a clinical rationale for the non-certification. (Mandatory)

HUM - 23 - Clinical Rationale for Non-Certification Requirements

Upon request from the patient, attending physician, or other ordering provider or facility rendering service, the

organization provides specific clinical rationale upon which the non-certification was based. (4)

UM Procedures

HUM - 24 - Reversal of Certification Determinations

The organization does not reverse a certification determination unless it receives new information that is relevant

to the certification and that was not available at the time of the original certification. (4)

HUM - 25 - Frequency of Continued Reviews

The organization ensures that the frequency of reviews for the extension of initial determinations is based on the

severity or complexity of the patient’s condition or on necessary treatment and discharge planning activity (i.e.,

not routinely conducted on a daily basis). (4)

Information Upon Which UM is Conducted

HUM - 26 - Scope of Review Information

The organization, when conducting routine prospective review, concurrent review, or retrospective review: (No

Weight)

(a) Accepts information from any reasonably reliable source that will assist in the certification

process; (2)

(b) Collects only the information necessary to certify the admission, procedure or treatment,

length of stay, or frequency or duration of services. (2)

(c) Does not routinely require hospitals, physicians, and other providers to numerically code

diagnoses or procedures to be considered for certification, but may request such codes, if

available; (4)

69
(d) Does not routinely request copies of all medical records on all patients reviewed; (4)

(e) Requires only the section(s) of the medical record necessary in that specific case to certify

medical necessity or appropriateness of the admission or extension of stay, frequency or duration

of service, or length of anticipated inability to return to work; and (4)

(f) Administers a process to share all clinical and demographic information on individual patients

among its various clinical and administrative departments that have a need to know, to avoid

duplicate requests for information from enrollees or providers. (3)

HUM - 27 - Prospective and Concurrent Review Determinations

For prospective review and concurrent review, the organization bases review determinations solely on the medical

information obtained by the organization at the time of the review determination. (4)

HUM - 28 - Retrospective Review Determinations

For retrospective review, the organization bases review determinations solely on the medical information

available to the attending physician or ordering provider at the time the medical care was provided. (4)

HUM - 29 - Lack of Information Policy and Procedure

The organization implements policies and procedures to address situations in which it has insufficient information

to conduct a review. Such policies and procedures provide for: (4)

(a) Procedural time frames that are appropriate to the clinical circumstances of the review (i.e.,

prospective, concurrent, retrospective reviews); (4)

(b) Resolution of cases in which the necessary information is not provided to the

organization within specified time frames; and (4)

(c) Processes by which the organization issues an administrative non-certification due to lack of

information. (4)

Appeals Considerations

70
HUM - 30 - Non-Certification Appeals Process

The organization maintains a formal process to consider appeals of non-certifications that includes: (No Weight)

(a) The availability of standard appeal for non-urgent cases and expedited appeal for cases

involving urgent care; and (Mandatory)

(b) Written policies and procedures that: (No Weight)

(i) Clearly describe the appeal process, including the right to appeal of the

patient, provider, or facility rendering service; (Mandatory)

(ii) Provide for explicit time frames for each stage of the appeal resolution

process; and (Mandatory)

(iii) Are available, upon request, to any patient, provider, or facility rendering

service. (Mandatory)

HUM - 31 - Appeals Process

As part of the appeals process: (No Weight)

(a) The organization provides the patient, provider, or facility rendering service the opportunity

to submit written comments, documents, records, and other information relating to the case;

(Mandatory)

(b) Takes all such information into account during the appeals process without regard to whether

such information was submitted or considered in the initial consideration of the case; and

(Mandatory)

(c) In instance of a first level appeal, the organization implements the decision of the first level

clinical appeal if it overturns the initial denial. (Mandatory)

HUM - 32 - Appeal Peer Reviewer Qualifications

Appeals considerations are conducted by health professionals who: (No Weight)

(a) Are clinical peers; (Mandatory)

(b) Hold an active, unrestricted license to practice medicine or a health profession; (Mandatory)

71
(c) Are board-certified (if applicable) by: (3)

(i) A specialty board approved by the American Board of Medical Specialties

(doctors of medicine); or (No Weight)

(ii) The Advisory Board of Osteopathic Specialists from the major areas of

clinical services (doctors of osteopathic medicine); (No Weight)

(d) Are in the same profession and in a similar specialty as typically manages the medical

condition, procedure, or treatment as mutually deemed appropriate; and (Mandatory)

(e) Are neither the individual who made the original non-certification, nor the subordinate of such

an individual. (Mandatory)

HUM - 33 - Expedited Appeals Process Timeframe

Expedited appeals are completed with verbal notification of determination to the requesting party within

72 hours of the request followed by a written confirmation of the notification within 3 calendar days to

the patient and attending physician or other ordering provider or facility rendering service. (Mandatory)

HUM - 34 - Standard Appeals Process Timeframe

Standard appeals are completed, and written notification of the appeal decision issued, within 30

calendar days of the receipt of the request for appeal to the patient and attending physician or other

ordering provider or facility rendering service.

(Mandatory)

HUM - 35 - Written Notice of Upheld Non-Certifications

For appeals determinations, the organization issues written notification of the adverse appeal decision to the

patient and attending physician or other ordering provider or facility rendering service that includes: (No Weight)

(a) The principal reasons for the determination to uphold the non-certification; (4)

(b) A statement that the clinical rationale used in making the appeal decision will be provided, in

writing, upon request; and (4)

(c) Information about additional appeal mechanisms available, if any. (4)

72
HUM - 36 - Appeal Record Documentation

The organization maintains records for each appeal that includes: (No Weight)

(a) The name of the patient, provider, and/or facility rendering service; (3)

(b) Copies of all correspondence from the patient, provider, or facility rendering service and

the organization regarding the appeal; (3)

(c) Dates of appeal reviews, documentation of actions taken, and final resolution; (3)

(d) Minutes or transcripts of appeal proceedings (if any); and (3)

(e) Name and credentials of the clinical peer that meets the qualifications in Standard UM 32. (3)

73