POLICY AND PROCEDURE

RELATING TO

Health Utilization Management Standards

Prepared by

The Kansas Insurance Department

August 23, 2007

POLICY AND PROCEDURE RELATING TO

Health Utilization Management Standards

August 23, 2007

This Policy and Procedure is an adaptation of URAC Health Utilization Management Accreditation, Version 5.0, which provides Core Standards, Version 2.0, and Health Utilization Management Standards for Utilization Review Organizations. Deletions in these standards have been stricken through and additions are underlined.

URAC, an independent, nonprofit organization, is well-known as a leader in promoting health care quality through its accreditation and certification programs. URAC offers a wide range of quality benchmarking programs and services that keep pace with the rapid changes in the health care system, and provide a symbol of excellence for organizations to validate their commitment to quality and accountability. Through its broad-based governance structure and an inclusive standards development process, URAC ensures that all stakeholders are represented in establishing meaningful quality measures for the entire health care industry.

Important: To achieve URAC Health Utilization Management Accreditation, an organization must comply with both URAC’s Core Standards and Health Utilization Management Standards. Both sets of standards are included in this document. Certification by URAC is prima facie evidence of that these standards are currently being met.

Except as provided in K.S.A. 40-22a06(b) and amendments thereto, each organization offering utilization review services that is required to apply for a certificate pursuant to K.S.A. 40-22a01 et seq., and amendments thereto, shall comply with these regulations. The utilization review services subject to these regulations shall include the following:

(a) Prospective, concurrent, and retrospective utilization review for inpatient and outpatient care conducted by a health care provider; and

(b) utilization review activity conducted by a health care provider in connection with health benefit plans.

Notwithstanding adherence to the standards prescribed by these regulations, the decision as to what treatment to prescribe for an individual patient shall remain that of the health care provider, and either the patient or the patient's representative. The final decision as to whether the prescribed treatment constitutes a covered benefit shall be the responsibility of the claims administrator or health benefit plan.

If specified in the health benefit plan which imposes the utilization review requirements:

(a)  The insured individual seeking the health care services shall be responsible for notifying the utilization review organization in a timely manner and initiating the request for certification of health care services; and

(b)  any health care provider or responsible patient representative, including a family member, may assist in fulfilling the responsibility of initiating the request for certification.

Important: This document is intended to provide a basic understanding of the accreditation standards. It does not include interpretive information, scoring information, or other guidance necessary for a detailed understanding of the standards and the accreditation process. This information is contained in the Program Guide for this accreditation program, which may be purchased on URAC’s Web site at www.urac.org, or by calling (202) 216-9010.

Note: Defined terms appear in italics throughout this document. A definitions section follows the standards.

Core Standards

Version 2.0

Organizational Structure

Core 1 – Organizational Structure

The organization has a clearly defined organizational structure outlining direct and indirect oversight responsibility throughout the organization.

Core 2 – Organization Documents

Organization’s documents address:

(a) Mission statement;

(b) Organizational framework for program;

(c) A description of the services delivered by the organization and how those services are delivered;

(d) The population served; and

(e) Organizational oversight and reporting requirements of the program.

Policies and Procedures

Core 3 – Policy and Procedure Maintenance, Review, and Approval

The organization:

(a) Maintains and complies with written policies and procedures that govern all aspects of its operations;

(b) Maintains a master list of all such policies and procedures;

(c) Reviews policies and procedures no less than annually and revises as necessary; and

(d) Includes the following on all policies and procedures:

(i) Effective dates, review dates, including the date of the most recent

revision; and

(ii) Identification of approval authority.

Staff Qualifications

Core 4 – Job Descriptions

The organization has written job descriptions for staff that address:

(a) Required education, training, and/or professional experience;

(b) Expected professional competencies;

(c) Appropriate licensure/certification requirements; and

(d) Scope of role and responsibilities.

Core 5 – Staff Qualifications

Staff meets qualifications as outlined in written job descriptions.

Core 6 - Credentialing

The organization implements a policy to:

(a) Verify the current licensure and credentials of licensed or certified personnel/consultants upon hire, and thereafter no less than every 3 years;

(b) Require staff to notify organization in a timely manner of an adverse change in licensure or certification status; and

(c) Implement corrective action in response to adverse changes in licensure or certification status.

Staff Management

Core 7 – Staff Training Program

The organization has a training program that includes:

(a) Initial orientation and/or training for all staff before assuming assigned roles and responsibilities;

(b) Ongoing training, at a minimum annually, to maintain professional competency;

(c) Training in URAC utilization management standards as appropriate to job functions;

(d) Training in state and regulatory requirements as related to job functions;

(e) Conflict of interest;

(f) Confidentiality;

(g) Delegation oversight, if necessary; and

(h) Documentation of all training provided for staff.

Core 8 – Staff Operational Tools and Support

The organization provides staff with:

(a) Written operational policies and procedures appropriate to their jobs; and

(b) Clinical decision support tools as appropriate.

Core 9 – Staff Assessment Program

The organization maintains a formal assessment program for individual staff members that includes an annual performance appraisal and a review of relevant documentation produced by that individual staff member.

Clinical Oversight

Core 10 – Senior Clinical Staff Requirements

The organization designates at least one senior clinical staff person who has:

(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 Board);

(b) Qualifications to perform clinical oversight for the services provided; and

(c) Post-graduate experience in direct patient care; and

(d) Board certification (if the senior clinical staff person is an M.D. or D.O.).

Core 11 – Senior Clinical Staff Responsibilities

The senior clinical staff person:

(a) Provides guidance for all clinical aspects of program;

(b) Is responsible for clinical aspects of program; and

(c) Has periodic consultation with practitioners in the field.

Inter-Departmental Coordination

Core 12 – 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.

Information Management

Core 13 - Information Management

The organization implements information system(s) (electronic, paper or both) to collect, maintain, and analyze information necessary for organizational management that:

(a) Provides for data integrity;

(b) Provides for data confidentiality and security;

(c) Includes a disaster recovery plan that;

(i) Is tested at least every two years; and

(ii) Addresses identified areas for improvement; and

(d) Includes a plan for storage, maintenance, and destruction.

Business Relationships

Core 14 – Business Relationships

The organization maintains signed written agreements with all clients describing the scope of the business arrangement.

Oversight of Delegated Functions

Core 15 – Delegation Review Criteria

The organization establishes and implements criteria and processes for an assessment prior to the delegation of functions.

Core 16 – Delegation Review

Prior to delegating functions to another entity, the organization:

(a) Conducts a review of the potential contractor’s policies and procedures and capacity to perform delegated functions; and

(b) Outlines and follows criteria and processes for approving contractors.

Core 17 – Delegation Contracts

The organization enters into written agreements with contractors that:

(a) Specify those responsibilities delegated to the contractor and those retained by the organization;

(b) Require that services be performed in accordance with the organization’s requirements and URAC utilization management standards;

(c) Require notification to the organization of any material change in the contractor’s performance of delegated functions;

(d) Specify that the organization may conduct surveys of the contractor, as needed;

(e) Require that the contractor submit periodic reports to the organization regarding the performance of its delegated responsibilities;

(f) Specify recourse and/or sanctions if the contractor does not make corrections to identified problems within a specified period;

(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

(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 utilization management standards.

Core 18 – Delegation Oversight

The organization implements an oversight mechanism for delegated functions that includes:

(a) A periodic review (no less than annually) of the contractor’s policies and procedures and documentation of quality activities for related delegated functions;

(b) A process to verify (no less than annually) the contractor’s compliance with contractual requirements and policies and procedures; and

(c) A mechanism to monitor financial incentives to ensure that quality of care or service is not compromised.

Regulatory Compliance

Core 19 – Regulatory Compliance

The organization implements a regulatory compliance program that:

(a) Tracks applicable laws and regulations in the jurisdictions where the organization conducts business; and

(b) Ensures the organization’s compliance with applicable laws and regulations.

Financial Incentives

Core 20 – 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.

Communications

Core 21 – Communication Practices

The organization follows marketing and communication practices that include:

(a) Mechanisms to clearly and accurately communicate information about services to consumer and clients;

(b) Safeguards against misrepresentations about the organization’s services;

(c) A formal process of inter-departmental review of marketing materials before dissemination; and

(d) Monitoring of existing materials for accuracy.

Core 22 – Consumer Communication Plan

The organization documents and has a mechanism for informing consumers and clients of their rights and responsibilities, including:

(a) How to obtain services; and

(b) How to submit a complaint or appeal.

Consumer Protection

Core 23 – 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.

Core 24 – Confidentiality of Individually-Identifiable Health Information

The organization establishes and implements a policy and procedure to protect the confidentiality of individually-identifiable health information that:

(a) Identifies how individually-identifiable health information will be used;

(b) Specifies that individually-identifiable health information is used only for purposes necessary for conducting the business of the organization, including evaluation activities;

(c) Addresses who will have access to individually-identifiable health information collected by the organization;

(d) Addresses oral, written, or electronic communication and records that are transmitted or stored;

(e) Address the responsibility of organization employees, committee members, and board members to preserve the confidentiality of individually-identifiable health information; and

(f) Requires employees, committee members, and board members of the organization to sign a statement that they understand their responsibility to preserve confidentiality.

Consumer Satisfaction

Core 25 – Consumer Satisfaction

The organization implements a mechanism to collect or obtain information about consumer satisfaction with services provided by the organization.

Access to Services

Core 26 – Access to and Monitoring of Services

The organization:

(a) Establishes standards to assure that consumers or clients have access to services: and

(b) Defines and monitors its performance with respect to the access standards.

Complaints and Appeals

Core 27 – Complaint and Appeal System

The organization maintains a system to receive and respond in a timely manner to complaints and, when appropriate, inform consumers of their rights to submit an appeal.

Core 28 – Appeal Process

The organization maintains a formal appeal resolution process that includes:

(a) Written notice of final determination with an explanation of the reason for the determination;

(b) Notification of the process for seeking further review, if available; and

(c) A reasonable, specified time frame for resolution and response.

Core 29 – Complaint and Appeal Reporting

The organization reports analysis of the complaints and appeals to the quality management committee (see Core 33).

Quality Improvement/Management

Core 30 – 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.

Core 31 – Quality Management Program Resources

The organization employs staff and provides resources necessary to support the day-to-day operations of the quality management program.

Core 32 – Quality Management Program Requirements

The organization has a written description for its quality management program that:

(a) Is approved by the organization’s governing body;

(b) Defines the scope, objectives, activities, and structure of the quality management program;

(c) Is reviewed and updated by the quality management committee at least annually;

(d) Defines the roles and responsibilities of the quality management committee; and

(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.

Core 33 – Quality Management Committee

The organization has a quality management committee that:

(a) Is granted authority for quality management by the organization’s governing body;

(b) Provides on-going reporting to the organization’s governing body;

(c) Meets at least quarterly;

(d) Maintains approved minutes of all committee meetings;

(e) If applicable, includes at least one participating provider or receives input from a participating provider committee (such as a Physician Advisory Group);

(f) Provides guidance to staff on quality management priorities and projects;

(g) Approves the quality improvement projects to undertake;

(h) Monitors progress in meeting quality improvement goals; and

(i) Evaluates the effectiveness of the quality management program at least annually.

Core 34 – Quality Management Documentation

The organization, as part of its quality management program, provides written documentation of:

(a) Ongoing monitoring for compliance with URAC utilization management standards;

(b) Objectives and approaches utilized in the monitoring and evaluation of activities;

(c) Identification and tracking and trending of key indicators relevant to the scope of the entire organization and related to:

(i) Consumer and health care services; or

(ii) For organizations who do not interact with consumers, client services;

(d) The implementation of action plans to improve or correct identified problems;

(e) The mechanisms to communicate the results of such activities to staff; and

(f) The mechanisms to communicate the results of such activities to the quality management committee.

Core 35 – Quality Improvement Project Requirements

For each quality improvement project, the organization utilizes valid techniques comparable over time to:

(a) Develop quantifiable measures;

(b) Measure baseline level of performance; and re-measure level of performance at least annually; and

(c) Establish measurable goals for quality improvement.

Core 36 – Quality Improvement Project Goals and Measurement

For each quality improvement project, the organization:

(a) Designs and implements strategies to improve performance;

(b) Establishes projected time frames for meeting goals for quality improvement;

(c) Documents changes or improvements relative to the baseline measurement;

(d) Conducts at least one remeasurement prior to re-accreditation; and

(e) Conducts a barrier analysis, if the performance goals are not met.

Core 37 – Clinical, Error Reduction, and Consumer Safety Requirements

At any given time, the organization maintains no less than two quality improvement projects.

(a) At least one quality improvement project that:

(i) Focuses on consumers; or for organizations who do not interact with consumers, client services;

(ii) Relates to key indicators of quality as described in 34(c); and

(iii) Involves a senior clinical staff person in judgments about clinical aspects of performance, if the quality improvement project is clinical in nature; and

(b) At least one quality improvement project focuses on error reduction and/or consumer safety.

(i) Consumer safety QIPs (Quality Improvement Procedures) are required of the following programs: HUM (“Health Utilization Management”), WCUM, HCC, HP, DM, IRO, and CM.

(ii) Error reduction QIPs are required of all accreditation programs that do not conduct consumer safety QIPs.

Health Utilization Management Standards

Version 5.0

Review Criteria

UM 1 – Review Criteria Requirements

The organization utilizes explicit clinical review criteria or scripts that are:

(a) Developed with involvement from appropriate providers with current knowledge relevant to the criteria or scripts under review;

(b) Based on current clinical principles and processes;

(c) Evaluated at least annually and updated if necessary by:

(i) the organization itself; and

(ii) appropriate, actively practicing physicians and other providers with current knowledge relevant to the criteria or scripts under review, and;

(d) Approved by the medical director (or equivalent designate) or clinical director (or equivalent designate).

Accessibility of Review Services

UM 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 working day in each the central time zone where the organization conducts at least two percent of its review activities.

UM 3 – Review Service Communication and Timeframes

The organization maintains processes to:

(a) Receive communications from providers and patients during the business day and after business hours;

(b) Respond to communications within one business day; and

(c) Conduct its outgoing communications related to utilization management during providers’ reasonable and normal business hours, unless otherwise mutually agreed.

UM 4 – Review Service Disclosures

The organization:

(a) Requires utilization management staff to identify themselves by name, title, and organization name; and

(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.

UM 5 – Onsite Review Requirements

For on-site review services, the organization:

(a) Requires on-site reviewers to carry a picture ID with full name and the name of the organization;

(b) Schedules reviews at least one business day in advance, unless otherwise agreed; and

(c) Requires the on-site reviewers to follow reasonable hospital or facility procedures, including checking in with designated hospital or facility personnel.

UM 6

[This Standard number is reserved to synchronize with URAC’s Workers’

Compensation Utilization Management Standards. There is no current

Standard UM 6.]

Initial Screening

UM 7 – Limitations in Use of Non-Clinical Staff

For initial screening, the organization limits use of non-clinical administrative staff to:

(a) Performance of “review of service requests” for completeness of information;

(b) Collection and transfer of non-clinical data;

(c) Acquisition of structured clinical data; and

(d) Activities that do not require evaluation or interpretation of clinical information.

UM 8 – Pre-Review Screening Staff Oversight

The organization ensures that licensed health professionals are available to non-clinical administrative staff while performing initial screening.

UM 9 – Pre-Review Screening Non-Certifications

The organization does not issue non-certifications based on initial screening.

Initial Clinical Review

UM 10 – Initial Clinical Reviewer Qualifications

Individuals who conduct initial clinical review:

(a) Are appropriate health professionals; and

(b) Possess an active professional relevant license.

UM 11 – Initial Clinical Reviewer Resources

Individuals who conduct initial clinical review have access to consultation with a:

(a) Licensed doctor of medicine or doctor of osteopathic medicine; or

(b) Licensed health professional in the same licensure category as the ordering

provider; or

(c) Health professional with the same clinical education as the ordering provider in clinical specialties where licensure is not issued.

UM 12 – Initial Clinical Reviewer Non-Certifications

The organization does not issue non-certifications based on initial clinical review.

Peer Clinical Review

UM 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.

UM 14 – Peer Clinical Reviewer Qualifications

Individuals who conduct peer clinical review:

(a) Are appropriate health professionals;

(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

(c) Hold a current and valid license:

(i) in the same licensure category as the ordering provider; or

(ii) as a doctor of medicine or doctor of osteopathic medicine.

Peer-to-Peer Conversation

UM 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.

UM 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 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 the provider and consumer of the right to initiate an appeal and the procedure to do so.

Timeframes for Initial UM Decision

UM 17 – Prospective Review Timeframes

For prospective review, the organization issues a determination:

(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

(b) Within 15 calendar days, of the receipt of request for a utilization management determination, if it is a non-urgent case.

(c) For non-urgent cases this period may be extended one time by the organization for up to 15 calendar days:

(i) Provided that the organization determines that an extension is necessary because of matters beyond the control of the organization; and

(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

(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.

UM 18 – Retrospective Review Timeframes

For retrospective review, the organization issues a determination:

(a) Within 30 calendar days of the receipt of request for a utilization management determination.

(b) This period may be extended one time by the organization for up to 15 calendar days:

(i) Provided that the organization