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