"Preferred Provider Network (Ppn) License Application Form" - Connecticut

Preferred Provider Network (Ppn) License Application Form is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

Form Details:

  • Released on July 6, 2015;
  • The latest edition currently provided by the Connecticut Insurance Department;
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Download "Preferred Provider Network (Ppn) License Application Form" - Connecticut

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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Preferred Provider Network (PPN)
License Instructions and Application (Initial)
Connecticut General Statutes § 38a-479aa requires all Preferred Provider Networks (PPNs)
offering services in the State of Connecticut to be licensed by the Connecticut Insurance
Department (“Department”). If you have any questions about your responsibility to be
licensed, please refer to Conn. Gen. Stat. §38a-479aa and any applicable amendments.
Instructions:
To assure that a PPN license be issued prior to offering services in Connecticut, the
Department recommends that applications be submitted two months in advance. Connecticut
law requires that license renewal applications be submitted by March 1st of each year. If
your network meets the guidelines for licensure, an invoice for the license fee of $2,750 will be
forwarded to you. This invoice must be paid prior to the license effective date.
The application must be filled out, completed, and signed by the CEO of the PPN entity
certifying that all information provided is true and accurate.
Submit your application and attachments to:
Peter.Nakano@ct.gov
DO NOT SUBMIT THE LICENSE FEE WITH THIS APPLICATION.
You will be billed.
Once licensed, the law requires the PPN to submit quarterly and annual financial reports. To
comply, please refer to Conn. Gen. Stat. §38a-479aa and forward those reports to the Department at
the address above.
Revised 7/6/2015
PPN License – Initial Application
Page 1 of 9
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Preferred Provider Network (PPN)
License Instructions and Application (Initial)
Connecticut General Statutes § 38a-479aa requires all Preferred Provider Networks (PPNs)
offering services in the State of Connecticut to be licensed by the Connecticut Insurance
Department (“Department”). If you have any questions about your responsibility to be
licensed, please refer to Conn. Gen. Stat. §38a-479aa and any applicable amendments.
Instructions:
To assure that a PPN license be issued prior to offering services in Connecticut, the
Department recommends that applications be submitted two months in advance. Connecticut
law requires that license renewal applications be submitted by March 1st of each year. If
your network meets the guidelines for licensure, an invoice for the license fee of $2,750 will be
forwarded to you. This invoice must be paid prior to the license effective date.
The application must be filled out, completed, and signed by the CEO of the PPN entity
certifying that all information provided is true and accurate.
Submit your application and attachments to:
Peter.Nakano@ct.gov
DO NOT SUBMIT THE LICENSE FEE WITH THIS APPLICATION.
You will be billed.
Once licensed, the law requires the PPN to submit quarterly and annual financial reports. To
comply, please refer to Conn. Gen. Stat. §38a-479aa and forward those reports to the Department at
the address above.
Revised 7/6/2015
PPN License – Initial Application
Page 1 of 9
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Preferred Provider Network (PPN)
License Instructions and Application (Initial)
Name of PPN:
PPN Tax Identification Number (TIN/FEIN):
PPN Business Address:
PPN Mailing Address (if different):
PPN Phone Number:
Contact Information (used by the Department for all future correspondence):
Name:
Title:
Mailing Address:
Phone Number:
FAX Number:
E-mail Address:
Does your PPN provide services for workers’ compensation only?
No
Yes
If YES, you are not required to complete this application. Please return this page and the signed
CEO Certification (pages 8) to the Insurance Department at the address on the Instructions page
Is your organization registered with the Department as a Pharmacy Benefit Manager (“PBM”) pursuant to
Conn. Gen. Stat. Secs. 38a-479aaa et seq.?
No
Yes
If YES, you are not required to complete this application. Please return this page and the signed
CEO Certification (pages 8) to the Insurance Department at the address on the Instructions page
Revised 7/6/2015
PPN License – Initial Application
Page 2 of 9
Name and description of controlling company or organization:
Controlling company’s or organization’s contact name:
Business Address:
Mailing Address (if different):
Name of related or predecessor controlling company or organization:
Address:
Explain current relationship with related or predecessor controlling company:
Has any suspension, sanction or disciplinary action been taken against the entity in Connecticut or any
other state over the past ten years? If so, please provide us with a complete list of all actions taken, on an
annual basis. This includes actions taken against the entity not just related to PPN activity but also
related to any other activity provided by the licensed entity, including but not limited to, TPA or UR
activity.
No
Yes
If answered yes, explain:
Has any suspension, sanction or disciplinary action been taken against the controlling company or
organization in Connecticut or any other state over the past ten years? If so, please provide us with a
complete list of all actions taken, on an annual basis. This includes actions taken against the entity not
just related to PPN activity but also related to any other activity provided by the licensed entity, including
but not limited to, TPA or UR activity.
No
Yes
If answered yes, explain:
Revised 7/6/2015
PPN License – Initial Application
Page 3 of 9
Describe the PPN’s service area:
How many total enrollees are served by the PPN?
Nationwide:
Connecticut:
List participating hospitals in Connecticut:
Name and address of the person to whom applications may be made for participation:
List all entities on whose behalf the PPN has contracts or agreements to provide pharmacy benefit
services to Connecticut enrollees (e.g. Managed Care Organizations):
Indicate the type(s) of reimbursement arrangements that the PPN enters into with entities on whose behalf
the PPN has contracts or agreements to provide health care services to Connecticut enrollees (e.g.
Managed Care Organizations/MCO):
Capitation
Fee for Service
Other -- Please explain:
Revised 7/6/2015
PPN License – Initial Application
Page 4 of 9
Indicate types of services that the PPN provides for entities on whose behalf the PPN has contracts or
agreements to provide health care services to Connecticut enrollees (e.g. Managed Care Organizations):
Medical services
Utilization Review – if checked, your CT License Number: ______________________
Claims administration
Dental Services
Other – List types of services
If the PPN includes providers of vision services, the PPN certifies compliance with
§20-138b of the Connecticut General Statutes.
Indicate type(s) of reimbursement arrangements that the PPN enters into with participating providers:
Capitation
Fee for Service
Other -- Please explain:
PLEASE SUBMIT THE FOLLOWING AS ATTACHMENTS:
A Certificate from the Secretary of State affirming that the PPN and its controlling
company or organization (if applicable) is in good standing in Connecticut. In addition, for
out of state PPNs, controlling companies or organizations, a certificate that such PPN,
controlling company or organization is in good standing in its state of organization.
A list of the names, official positions, and occupations of members of the PPN’s board of
directors or other policy-making body and those executive officers who are responsible for
the PPN’s activities with respect to the health care services network
A list of the names, official positions and occupations of members of the controlling
company’s or organization’s board of directors and those executive officers who are
responsible for the controlling company’s or organization’s activities with regard to the
health care services network.
A list of the PPN’s principal owners.
A list of the controlling company’s or organization’s principal owners.
Revised 7/6/2015
PPN License – Initial Application
Page 5 of 9
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