Form WC50 "Application for Certification for Bill Screening" - Alabama

What Is Form WC50?

This is a legal form that was released by the Alabama Department of Labor - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

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Download Form WC50 "Application for Certification for Bill Screening" - Alabama

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DEPARTMENT OF LABOR
WORKERS' COMPENSATION DIVISION
APPLICATION FOR CERTIFICATION
BILL SCREENING AND UTILIZATION REVIEW
QUALIFICATIONS FOR UTILIZATION REVIEW ENTITY
Purpose and Scope of Application
To require certain persons or entities to obtain either a Limited or Full certification from the Department of
Labor, Workers' Compensation Division for Bill Screening and Utilization Review of Compensable Medical
Coverage under the Workers' Compensation Act.
The purpose of this application is to screen applicants to ensure that utilization review entities adhere to the
provisions of the Act for reasonable standards for conducting utilization review, foster greater coordination
and cooperation between health care providers and that utilization review agents are acting in the capacity
for which they are certified.
There is no requirement that outside utilization review entity vendors be hired to perform utilization review
activities in accordance with these rules. Entities qualified by the Department, either in a Limited or Full
Certification, may perform the functions as certified by the Department of Labor, Workers' Compensation
Division.
It is required that for the Certifications, either Full or Limited, the Entity applying for Certification
understand and have thorough knowledge of the requirements of the Law as it pertains to the application for
Certification.
Scoring of the Application shall determine the Certification to be issued.
Limited Certification will be issued for a score of 10, or to those entities applying for certification as
described in rule 480-5-5-.05 and 480-5-5-.06(1).
Full Certification will be issued for a score of 15, or to those entities applying for certification as described in
rule 480-5-5-.05 and 480-5-5-.06.
Revocation of Certification and the appeals process is as described in rule 480-5-5-.06 and 480-5-5-.23.
The Department of Labor maintains the right to inspect or verify that the information in the Application for
Certification is correct and truthful. The Entity shall produce necessary documentation to the Department of
Labor that would verify compliance and qualifications under any of the requirements of the Act. The
Department of Labor shall be specific as to what documentation is being requested.
Certification shall be issued for a period of two years.
DEPARTMENT OF LABOR
WORKERS' COMPENSATION DIVISION
APPLICATION FOR CERTIFICATION
BILL SCREENING AND UTILIZATION REVIEW
QUALIFICATIONS FOR UTILIZATION REVIEW ENTITY
Purpose and Scope of Application
To require certain persons or entities to obtain either a Limited or Full certification from the Department of
Labor, Workers' Compensation Division for Bill Screening and Utilization Review of Compensable Medical
Coverage under the Workers' Compensation Act.
The purpose of this application is to screen applicants to ensure that utilization review entities adhere to the
provisions of the Act for reasonable standards for conducting utilization review, foster greater coordination
and cooperation between health care providers and that utilization review agents are acting in the capacity
for which they are certified.
There is no requirement that outside utilization review entity vendors be hired to perform utilization review
activities in accordance with these rules. Entities qualified by the Department, either in a Limited or Full
Certification, may perform the functions as certified by the Department of Labor, Workers' Compensation
Division.
It is required that for the Certifications, either Full or Limited, the Entity applying for Certification
understand and have thorough knowledge of the requirements of the Law as it pertains to the application for
Certification.
Scoring of the Application shall determine the Certification to be issued.
Limited Certification will be issued for a score of 10, or to those entities applying for certification as
described in rule 480-5-5-.05 and 480-5-5-.06(1).
Full Certification will be issued for a score of 15, or to those entities applying for certification as described in
rule 480-5-5-.05 and 480-5-5-.06.
Revocation of Certification and the appeals process is as described in rule 480-5-5-.06 and 480-5-5-.23.
The Department of Labor maintains the right to inspect or verify that the information in the Application for
Certification is correct and truthful. The Entity shall produce necessary documentation to the Department of
Labor that would verify compliance and qualifications under any of the requirements of the Act. The
Department of Labor shall be specific as to what documentation is being requested.
Certification shall be issued for a period of two years.
DEPARTMENT OF LABOR
WORKERS' COMPENSATION DIVISION
APPLICATION FOR CERTIFICATION
BILL SCREENING AND UTILIZATION REVIEW
QUALIFICATIONS FOR UTILIZATION REVIEW ENTITY
AS DEFINED IN RULES 480-5-5-.05, 480-5-5-.06 AND 480-5-5-.07
1. GENERAL INFORMATION
_________________________________________________________________
Name of Agency
_________________________________________________________________
Address
(______)___________________________________
Telephone Number
(______)___________________________________
Toll Free Number
_________________________________________________________________
Contact Person
Title
__________________________________________
Email Address
********
2.
CERTIFICATION ALREADY HELD:
Certified by Alabama Department of Public Health (Act 94-786), Health
Care Services Utilization Review Act No_____(0) Yes_____(15)
Current AAHC/URAC Certification No_____(0) Yes_____(15)
If answer is YES, further completion of application is unnecessary,
If certified under the Act 94-786 or holding URAC Accreditation, attach a copy of certification and mail to the Department of Labor. See page four, sign,
and return this application to the Department of Labor, Division of Workers' Compensation.
TOTAL__________
WC5
Application as Utilization Review Entity
Page Two
3. PURPOSE FOR APPLICATION:
(I) Application for LIMITED CERTIFICATION AS A UTILIZATION REVIEW ENTITY FOR
PERFORMANCE OF APPROVALS ONLY.
a.
Approval of medical charges through bill screening methodology using the Maximum Fee Schedule and the application of
the appropriate adjudication rules, using criteria as set in 480-5-5-.05 for approvals only.
No_____(0) Yes_____(5)
b. Approval/Certification of testing, inpatient stays, outpatient care and any other requests for authorization of treatment
using criteria as set in 480-5-5-.01 through 480-5-5-.37.
No_____(0) Yes_____(5)
If answer is yes on either a or b of number 3, (I) complete the following:
i.__________________________________________________________________
Name of utilization review agency performing 1st thru 3rd level clinical review, if applicable.
ii.
Address
iii. (_____)_____________________________
Telephone Number
iv. (_____)_____________________________
Toll Free Number
Not applicable
_____(0)
Information Completed _____(10)
If applying Entity is requesting qualification only to approve certifications and medical services, no further completion of application is necessary. If Entity
will be using other Utilization Review Entities for 1st through 3rd Level Clinical Review as noted in 480-5-5-06, the Entity must have filed and received
certification from the Department of Labor, Workers' Compensation Division to perform Utilization Review. You must have a copy of their Certification
and you must notify that entity that they are the designated Utilization Review Entity under the Act.
TOTAL__________
WC 50
Application as Utilization Review Entity
Page Three
3. PURPOSE FOR APPLICATION continued
(II) Application for FULL CERTIFICATION AS AN UTILIZATION REVIEW ENTITY (Full certification
is necessary for denials of medical necessity)
a. Be qualified per rule 480-5-5-.06 (2), (6), (7) for First Level Clinical Reviewer
No_____(0) Yes_____(5)
b. Be qualified per rule 480-5-5-.06 (3), (6), (7) for Second Level Clinical Reviewer.
No_____(0) Yes_____(5)
c. Be qualified per rule 480-5-5-.06 (4), (6), (7) for Third Level Clinical Reviewer.
No_____(0) Yes_____(5)
TOTAL__________
If the applying Entity contracts for utilization review services at any Clinical level review, the applicant Entity will be responsible for ensuring that the
contractor has a valid certificate in effect for workers' compensation issued by the Department of Labor. The applicant Entity must have a copy of the
contractor's Certification as a Certified Entity and the applicant Entity shall notify that contractor that they are the designated Utilization Review Entity
under the Act. After completion of the above, read and sign page 4, and return completed application to the Department of Labor, Workers' Compensation
Division. An individual serving as a Clinical Reviewer for a URE does not have to be individually certified by the Department of Labor as a URE.
WC 50
Application as Utilization Review Entity
Page Four
STATEMENT OF CERTIFICATION
I (we) do hereby certify on behalf of____________________________ that I (we) have reviewed and do
solemnly swear or affirm that I (we) am (are) familiar with the Laws of Alabama relating to Workers'
Compensation, that I have complied with all of the requirements of the Alabama Workers' Compensation
Act and the Department's Administrative Code for Bill Screening and Utilization Management with written
procedures and policies describing the appeals process. All the foregoing information is true and complete
and correct to the best of my knowledge and belief.
__________________________________________________
Company
__________________________________________________
Signature of Affiant
__________________________________________________
Name (typewritten)
__________________________________________________
Title (typewritten)
Sworn to and Subscribed Before Me
This __________day of _________ 20_____
____________________________________
Notary Public
Mail to:
Department of Labor
Workers' Compensation Division
649 Monroe Street
Montgomery, Alabama 36131
WC 50
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