Health Plan & Health Network Standards v.5.0 Workshop
Westin Peachtree Plaza, Atlanta, GA
DAY ONE - Thursday, March 8, 2007
Agenda:
8:00 – 8:30
Registration and Continental Breakfast
8:30 – 9:15
Overview of Application and Accreditation Process
Participants will learn about URAC, its history and the role of its member organizations in
the development of accreditation standards. The session will provide an overview of how
standards are developed and changed by the URAC Standards Committee, and how
accreditation applications are reviewed by the URAC Accreditation Committee. This
session will also provide an overview of the application process for accreditation,
including:
 URAC assistance during the application process
 Choosing the right person in your organization to spearhead the process
 Types of documentation required
 Timeline of the accreditation process
 Who will need to be involved in the site visit
 Explanation of how "site" is defined
 Review of a typical site visit agenda
 Scoring Process
9:15 – 10:15
Network Management
This session describes the Network Management Standards by reviewing each of the
major categories of standards. For each category of standards, the purpose of standards,
the type of documentation expected and what the reviewer will be looking for in the
applicant’s documentation will be discussed. The major categories of the standards
include:
 Network Design and Maintenance
 Organizational Management
 Provider Relations
This session will also address problem areas relating to compliance with standards. Some
of the topics will discuss ensuring the implementation plan includes:
 Defines the scope of the Network
 Defines Standards for Provider Selection
 Defines Provider Availability and Accessibility
 Defines Network Management and Operations
 Defines Standards for Provider Contracting
 Disciplinary Action program for providers
 Provider Rights and Appeals
10:15 – 10:30 Break
Health Plan & Health Network Standards v.5.0 Workshop
Westin Peachtree Plaza, Atlanta, GA
DAY ONE - Thursday, March 8, 2007
Agenda (cont’d):
10:30 – 11:30 Provider Credentialing Standards
This session describes the Provider Credentialing Standards by reviewing each of the
major categories of standards. For each category of standards, the purpose of the
standards, the type of documentation expected and what the reviewer will be looking for
in the applicant’s documentation will be discussed. The major categories of the standards
include:
 Scope of Credentialing Program
 Credentialing Program Structure and Organization
 Application Process
 Recredentialing
 Credentialing Delegation
This session will also address problem areas relating to compliance with standards. Some
of the topics will discuss ensuring the implementation plan includes:
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Policies and procedures
Appropriate record keeping
Audit policies and tools
Definition and role of the Credentialing Committee
Use of CVOs- oversight and due—diligence issues
11:30 – 12:30 Consumer Protection
This session describes the Consumer Protection Standards by reviewing each of the
major categories of standards. For each category of standards, the purpose of the
standards, the type of documentation expected and what the reviewer will be looking for
in the applicant’s documentation will be discussed. The major categories of the standards
include:
 Confidentiality
 Marketing
 Member Relations
12:30 – 1:15
Lunch
1:15 – 2:15
Quality Management
This session describes the Quality Management Standards by reviewing each of the
major categories of standards. For each category of standards, the purpose of the
standards, the type of documentation expected and what the reviewer will be looking for
in the applicant’s documentation will be discussed. The major categories of the standards
include:
 Quality Management Structure and Organization
 Quality Management Process
This session will also address problem areas relating to compliance with standards. Some
of the topics will discuss ensuring the implementation plan includes:
 Policies and procedures
 Effective input from providers and operational areas
 Designing and monitoring performance improvement activities
Health Plan & Health Network Standards v.5.0 Workshop
Westin Peachtree Plaza, Atlanta, GA
DAY ONE - Thursday, March 8, 2007
Agenda (cont’d):
2:15 - 3:15
Core Standards
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Definitions
Intent of the Core Standards
Purpose of the Core Standards
This session addresses URAC's Core accreditation standards. URAC staff will review each
of the major categories of the standards and their relationship to the modular
accreditation approach. The purpose of the standards, the type of documentation
required, and what specific elements URAC will be looking for in the applicant's
documentation will be discussed.
Categories include:
Organizational Structure
Policies and Procedures
Inter-departmental Coordination
Information Management
Business Relationships
Oversight of Delegated/Sub-Contracted Functions
Staff Qualifications
Staff Management
Clinical Oversight
Regulatory Compliance
Quality
Quality
Quality
Quality
Management Program
Management Committee
Management Documentation
Improvement Projects
Financial Incentives
Communications
Satisfaction
Ability of Consumers to Access Services
Complaints and Appeals
3:15 – 3:30
Break
3:30 – 5:00
Core Standards (cont’d)
5:00
Adjourn Day One
Health Plan & Health Network Standards v.5.0 Workshop
Westin Peachtree Plaza, Atlanta, GA
DAY TWO -Friday, March 9, 2007
Agenda (cont’d):
8:00 – 8:30
Continental Breakfast
8:30 – 10:00
Overview of Health Utilization Management Standards v.5.0
This session addresses URAC’s health utilization management standards, which focus on
program/staff qualifications and the UM process. We will discuss the purpose of each
specific standard, the type of documentation required, and the specific elements URAC
will be looking for in the applicant’s documentation. Categories include:
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Definitions Used in the Standards
Standards Relating to Confidentiality
Standards Relating to Staff Qualifications
Standards Relating to UM Program Structure
Standards Relating to Access and On-Site Review Procedures
Standards Relating to Information Used in UM Decisions
Standards Relating to Procedures for Review Determinations
Standards Relating to Appeals of UM Decision
10:00 – 10:15 Break
10:15 – 12:15 Overview of Health Utilization Management Standards v.5.0 (cont’d)
12:15
Adjourn