This Policy/Procedure collection of information is reviewed at least annually, updated if necessary, and approved by the Medical Director
What is HUM Number 1- Review Criteria?
100
This program includes initial orientation, URAC training, confidentiality, documentation of training, and ongoing training in addition to other elements provided.
What is Core 27- Staff Training Program?
100
This "appropriate" document details Milliman Care Guidelines use in determining Length of Stay, Medical Necessity, and Appropriate Setting
What is "Criteria for Appropriateness of Medical Services Health Care Management Policy"?
100
"Urgent" review of no later than 72 hours of the receipt of request for a UM determination complies with this standard.
What is HUM 17- Prospective Review Time Frames?
100
This Medical Management Policy discusses "physical safeguards" in relation to protected information.
What is the Medical Management Confidentiality Policy?
200
"Hello, this is Connie, I'm a Nurse Case Manager calling from BCBS IL....." is part of the information the clinician needs to provide to meet this standard.
What is HUM 4- Review Service Disclosure?
200
These two standards address keeping information and individual identifiers protected by implementation of appropriate policies and procedures.
What are Core Standards 15 and 16 (Information Confidentiality and Security AND Confidentiality of Individually Identifiable Health Information)?
200
This policy addresses an individuals rights as related to access and release of PHI.
What is the HCM HIPAA Policy?
200
Within 30 calendar days of the receipt of the request for a UM determination is this standard for the HCSC clinician when looking at the case in the rear view mirror.
What is HUM 18- Retrospective Review Time Frame?
200
This new standard helps to reduce medical errors by implementation of mechanisms to address the potential issue and follow through to resolution.
What is HUM 24- Prospective Review Patient Safety?
300
Within one business day of receiving the request from the attending or ordering provider to discuss the decision; HCSC will provide a clinical peer for the discussion. This provision meets this standard.
What is HUM 16- Peer to Peer Conversation Alternate?
300
To meet these three standards; clinicians must have active and unrestricted licenses, appropriate to their discipline.
What are Core Standards 25 (Job Description) and 26 (Staff Qualifications) and HUM 10- Initial Clinical Reviewer Qualifications?
300
This policy instructs the user what to do in the event a member expressed suicidal thought or ideation.
What is the Medical Management Member/Staff Safety Policy?
300
This standard addresses the need for a response within 24 hours OR within 72 hours, depending on WHEN the request for the extension was received.
What is HUM 19- Concurrent Review Time Frames?
300
This document is reviewed and signed at the time of hire and on an annual basis.
What is the Confidentiality Statement and Policy?
400
This standard provides the right to appeal to the member, the facility, and/or the physician provider.
What is HUM 31- Non-Certification Appeals Process?
400
The projects focusing on Member Satisfaction and Discharge Planning and Documentation help HCSC clinicians and the organization as a whole stay compliant with this core standard.
What is Core 24- Quality Improvement Projects: Consumer Organizations?
400
This Policy helps the clinician know HOW and WHAT to let the member, provider, and/or facility when a certification decision has been made.
What is the Medical Management Standard Review and Discharge Planning Policy?
400
HCSC clinicians have this length of time to resolve member, provider, Blue Card, and other member complaints.
What is 30 Calendar Days?
400
Core 33- Financial Incentive Policy and Medical Management Policy "Financial Incentive Policy" help to ensure that our members' care is not compromised in order for staff to receive additional monies.
What is our Annual Performance Contingency Compensation/Bonus?
500
Responding to communications received from members and/or providers within one business day helps HCSC clinicians and the organization stay compliant with this standard.
What is HUM 3- Review Service Communication and Time Frames?
500
Milliman Care Guidelines, HCSC Policies, various workflows, and HCM and Medical Management policies are examples of tools provided to the clinician which meets the requirements of this standard.
What is Core 28- Staff Operational Tools and Support?
500
This policy, along with HUM 30 guide the clinician when little to no information was provided for the requested review.
What is the Medical Management Administrative Non-Certification Policy?
500
This is the Expedited Appeals Process Time Frame that must be followed in order for ASO groups to be compliant with HUM 35 Expedited Appeals Process Time Frame.
What is "Verbal notification of determination within 72 hours of the request followed by written notification within 3 calendar days"?
500
This is the Mission of URAC.
What is "To promote continuous improvement in the quality and efficiency of health care management through processes of accreditation and education"?