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

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

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  • Released on July 6, 2015;
  • The latest edition currently provided by the Connecticut Insurance Department;
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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Preferred Provider Network (PPN)
License Instructions and Application (Renewal)
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 confirmed without interruption in Connecticut, the
Department needs applications to 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 $2750 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 – Renewal Application
Page 1 of 8
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Preferred Provider Network (PPN)
License Instructions and Application (Renewal)
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 confirmed without interruption in Connecticut, the
Department needs applications to 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 $2750 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 – Renewal Application
Page 1 of 8
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Preferred Provider Network (PPN)
License Instructions and Application (Renewal)
Name of PPN:
PPN CT License Number:
PPN Tax Identification Number (TIN/FEIN):
PPN Business Address:
PPN Mailing Address (if different):
PPN Phone Number:
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 7) 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 7) to the Insurance Department at the address on the Instructions page
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 yes, explain:
Revised 7/6/2015
PPN License – Renewal Application
Page 2 of 8
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:
Describe the PPN’s service area:
How many total enrollees are served by the PPN:
Nationwide:
Connecticut:
List participating hospitals in Connecticut:
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):
Revised 7/6/2015
PPN License – Renewal Application
Page 3 of 8
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:
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:
Revised 7/6/2015
PPN License – Renewal Application
Page 4 of 8
PLEASE SUBMIT THE FOLLOWING AS ATTACHMENTS:
A list of participating primary care physicians, the specialty physicians and other providers,
including the number and percentage of each group’s capacity to accept new patients.
A description of the general criteria for selection and/or termination of providers.
A list of subcontractors of the PPN that provide health care services to Connecticut enrollees
and assume financial risk from the PPN; and to what extent each assumes risk. This does
not include individual participating providers.
A table of all major categories of health care services provided by the PPN.
Contingency plan describing how contracted health care services will be provided in the
event of insolvency.
* Proof that the PPN meets minimum security standards as defined in Conn. Gen. Stat. Sec.
38a-479aa(i) as amended by Public Act 07-191.
Proof can be in the form of a letter of credit, bond, surety, reinsurance, or reserve
exclusively held for “…use of paying any outstanding amounts owed participating providers
in the event of insolvency or nonpayment…” [Sample bond language is attached.]
Please note that the beneficiaries of the financial security instrument are the
members/providers. Under no circumstance should the State of Connecticut or the State of
Connecticut Insurance Department be named as the beneficiary.
The most recently concluded fiscal year-end financial statements for the PPN
AND
The most recently concluded fiscal year-end financial statements for the controlling
company or organization.
• If the last fiscal year-end financial statements (for the PPN and the controlling
company or organization) ended more than 90 days prior to your license
application date, you must also include an internally prepared financial statement
(using GAAP) for the quarter ending within the 90 days prior to that date. The
next fiscal year-end financials must be sent to the Department within 120 days of
your fiscal year-end.
• Financial statements must be “Reviewed” or “Audited” by an independent certified
public accountant (CPA) under U.S. generally accepted accounting principles
(GAAP).
• Any other material change since last year.
The PPN hereby certifies, from January 1, 2012 on, it shall maintain a network of
participating providers in Connecticut that is consistent with the National Committee for
Quality Assurance’s network adequacy requirements or URAC’s provider network access
and availability standards.
Revised 7/6/2015
PPN License – Renewal Application
Page 5 of 8
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