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Health Utilization Management Accreditation Overview
URAC is widely recognized by nearly every state and the federal government for our health utilization management accreditation program.
With our origins in utilization review and utilization management, URAC set the bar for Health Utilization Management (HUM) in 1990 with the development of the country's first utilization management accreditation standards. Now, URAC-accredited organizations serve patients in every state across the country.
With URAC’s HUM standards, organizations develop processes to maintain confidentiality and avoid conflict of interest in utilization management.
Our program continues to evolve as the health care landscape changes. Traditionally, utilization management focused more on cost containment methods; it is now seen as a valuable tool to ensure accessibility, quality and timeliness of care. With input from industry experts and valued clients, we have conducted numerous revisions to the original standards. This way, we keep pace with the changing health care industry while defining best practices grounded by real experience.
URAC Health Utilization Management Accreditation is the industry standard; it indicates your organization performs its utilization management functions in an effective, transparent and efficient manner.
Once you begin the process, your organization can be fully accredited in six months or less.
Modular Approach
URAC offers five modules to address the HUM functions performed by each organization, giving you the option to choose the one(s) most applicable to your business operations.
The five HUM modules are:
- Pre-Review Screening – Starts the prior authorization process through paper-based, automated, or semi-automated intake process.
- Initial Clinical Review – Conducts clinical reviews and forwards for peer review if unable to certify.
- Clinical Decision – Provides medical necessity review determination(s).
- Clinical Review – Develops clinical review criteria used to determine medical necessity.
- Comprehensive – Using clinical review criteria, determines the medical necessity of medical care, including appeals as applicable.
Our team can help you decide which module(s) are right for you. Applicant organizations may apply for up to four of the functional HUM Modules or the Comprehensive Module.
Health Utilization Management Accreditation Benefits
Earning the URAC Health Utilization Management Accreditation Seal is a mark of distinction for organizations that demonstrate their commitment to quality and HUM accountability. It also boosts your credibility among key stakeholders: patients, provider practices, facilities and purchasers.
Benefits of HUM Accreditation include
- Promoting the provision of consistent, unbiased medical necessity determinations by appropriately credentialed staff
- Enhancing your ability to improve the quality and effectiveness of patient care while eliminating unnecessary treatment and expense
- Developing systems for protecting patient safety and mitigating risks such as contraindicated treatments, adverse drug interactions or inappropriate treatment
- Validating compliance and adherence to applicable state and federal regulations
- Implementing risk management oversight and review protocols that help mitigate your organization's liabilities
- Developing a roadmap for ongoing utilization management process and quality improvements rooted in evidence-based treatment guidelines that enhance care delivery, lower overall health care costs and optimize operational efficiencies
In addition, URAC’s Modular approach means your HUM-accredited partners do not have to conduct delegation oversight; they will use your accreditation instead. This makes your organization an easy choice when they are selecting a service provider or delegated entity.
Who May Apply
To be eligible for URAC’s Health Utilization Management Accreditation, an organization must complete determination of medical necessity for medical and/or behavioral health clients, peer clinical review, and appeals as applicable. Organizations must be operating in the U.S. Download our Health Utilization Management Standards-at-a-Glance for more information.
