URAC and NCQA launch new accreditation programs

The Utilization Review & Accreditation Commission (URAC), a Washington, D.C.-based nonprofit organization, is launching a national claims processing accreditation program.

Guy D’Andrea, URAC senior v.p., told Drug Topics, "The claims process is very consistent with our historical focus on managed care operations. The new program was devised because we have identified that the claims process really affects patients’ experiences with managed care plans." He gave as examples decisions on whether certain therapies would be covered and also the timeliness of those decisions.

The fee for the accreditation program is $11,000, to be paid every other year. Accreditation lasts for two years.

Although D’Andrea said URAC expects pharmacy benefit managers, third-party administrators, and health insurers to benefit from pursuing claims processing accreditation, he noted that, "It’s a voluntary accreditation program. We have received a lot of interest throughout the standards development process from a whole range of healthcare organizations, including PBMs, and I think that interest will carry over to the implementation."

According to D’Andrea, URAC is the first organization to launch a national claims processing accreditation program. URAC’s accreditation "is an added mark of distinction companies can use in marketing their services, and it protects consumers," he said.

D’Andrea explained that during the accreditation process, URAC would examine the applicant’s claims processing operations and review documentation policies and procedures and organizational charts. "We also go on site and review and observe the operation directly, review cases or specific files to make sure they are operating according to the standards," he said.

In a separate development, the National Committee for Quality Assurance (NCQA) announced it has launched a Disease Management Accreditation and Certification program. Eighteen organizations have agreed to participate, including AdvancePCS, American Healthways, Caremark, GlaxoSmithKline HealthCare Management, Merck-Medco Managed Care, McKesson Health Solutions, and Wellcomm.

Perry Cohen, Pharm.D., The Pharmacy Group LLC, Glastonbury, Conn., believes NCQA’s program will be well received. "I think NCQA is a big deal because PBMs are trying to justify disease management programs, and the program will take off. NCQA’s disease management hits the heart of what PBMs do."

David Lorber, M.D., assistant v.p., medical affairs, AdvancePCS, said, "We’ve met with NCQA and URAC. We’re actively involved in helping develop these programs, and we have interest in them as they apply to us. We have a lot of managed care clients, and they are certified. Because we perform functions for them that are part of their certification, we have to be in compliance with those same rules."

When it comes to URAC’s program, Lorber said, "There may be one claims process standard. The question is, Is that an important enough standard that we need to have everybody standardized for everything, or do we just need to seek accreditation in major competencies of the company? You want to be sure you can pass them or will be able to gear up enough to pass them. It is costly, time-consuming, and labor-intensive for any company to seek accreditation. You have to take all of that into consideration before you seek accreditation," he said.

Sandra Levy

Highlights of URAC's claims processing standards

• The claim forms and/or related materials clearly state the format, information, and documentation required for a claim to be considered a clean claim; method(s) by which claimants may submit claims; and timeframes for the submission of claims.

• The claim forms and/or related materials clearly state how a claimant (or a prospective claimant) may contact the organization for additional information about the claims process in general, including the information scripted in the above standard and information on the status of a specific claim.

• The organization maintains a telephone information service that provides claimants access by a toll-free or collect telephone line at a minimum from 9 a.m. to 4 p.m. of each normal business day in each time zone where at least 2% of claimants reside.

• The organization maintains a Web site that provides information as required under the first standard above.

•The organization has a process to provide, upon request from a claimant or potential claimant, specific payment rules and policies.

• The organization has a system to track the status of all claims by consumer name, consumer identification number, claim tracking number, date of service, and group contract (if applicable).

• The organization uses an internally consistent and uniform process to adjudicate the claim, as determined by the organization itself and subject to specific regulatory requirements, as applicable.

• For each benefit program for which the organization processes claims, the organization establishes criteria that clearly define the requirements for a clean claim.

• The organization tracks claims processing quality indicators and reports the results, no less than quarterly, to the quality management committee.

• The organization notifies claimants of benefit determinations and pays any benefits due within 30 calendar days of the receipt of the claim, or within 45 calendar days of the receipt of the claim when all of the following conditions are met: an extension is necessary due to matters beyond the control of the organization, the organization documents the specific reason for the extension in the claim file, and the organization notifies the claimant of the extension before the expiration of the 30-day period required.

• The organization allows claimants at least 180 calendar days after the receipt of a notice of an adverse benefit determination or benefit calculation to initiate the appeals process.

Sandra Levy. URAC launches national claims processing accreditation program.

Drug Topics

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