"Utilization Review Certification and/Or Registration Application Form" - Oklahoma

Utilization Review Certification and/Or Registration Application Form is a legal document that was released by the Oklahoma Insurance Department - a government authority operating within Oklahoma.

Form Details:

  • The latest edition currently provided by the Oklahoma Insurance Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Oklahoma Insurance Department.

ADVERTISEMENT
ADVERTISEMENT

Download "Utilization Review Certification and/Or Registration Application Form" - Oklahoma

1354 times
Rate (4.5 / 5) 67 votes
OKLAHOMA INSURANCE DEPARTMENT
Reset Fields
Rate and Form Compliance Division
Utilization Review Section
Five Corporate Plaza
3625 NW 56
Street, Suite 100
TH
Oklahoma City, OK 73112
UTILIZATION REVIEW
CERTIFICATION and/or REGISTRATION APPLICATION
This completed Application and all Exhibits must be submitted via SERFF. The Application Fee of
$500.00 must be submitted via SERFF as well, using EFT. Be sure to complete all fields, sign and have
the Application notarized.
1. Name:
2. Federal Employee Identification Number (FEIN):
3. The application is the following type of business (check only one entity):
Private Review Agent (36 O.S. 6558).
“In-House” Utilization Review (36 O.S. 6559) (Insurance Companies, Not-for-profit
Hospital Services, and Medical Indemnity Plans).
Oklahoma State and Education Employees Group Insurance Board (74 O.S. 1306.2).
4. Business Street Address (Do not use a PO Box):
City, State Zip Code:
5. Business Mailing Address (Street or PO Box):
City, State Zip Code:
6. Business Telephone Number:
Toll-Free Number:
G:\DATA\SERFF\Speed to Market Initiatives\OK\License and Cert of Auth\UR Forms\UR Certification and-or Registration Application.docx
1
OKLAHOMA INSURANCE DEPARTMENT
Reset Fields
Rate and Form Compliance Division
Utilization Review Section
Five Corporate Plaza
3625 NW 56
Street, Suite 100
TH
Oklahoma City, OK 73112
UTILIZATION REVIEW
CERTIFICATION and/or REGISTRATION APPLICATION
This completed Application and all Exhibits must be submitted via SERFF. The Application Fee of
$500.00 must be submitted via SERFF as well, using EFT. Be sure to complete all fields, sign and have
the Application notarized.
1. Name:
2. Federal Employee Identification Number (FEIN):
3. The application is the following type of business (check only one entity):
Private Review Agent (36 O.S. 6558).
“In-House” Utilization Review (36 O.S. 6559) (Insurance Companies, Not-for-profit
Hospital Services, and Medical Indemnity Plans).
Oklahoma State and Education Employees Group Insurance Board (74 O.S. 1306.2).
4. Business Street Address (Do not use a PO Box):
City, State Zip Code:
5. Business Mailing Address (Street or PO Box):
City, State Zip Code:
6. Business Telephone Number:
Toll-Free Number:
G:\DATA\SERFF\Speed to Market Initiatives\OK\License and Cert of Auth\UR Forms\UR Certification and-or Registration Application.docx
1
7. Contact Person:
Contact Person’s Telephone Number:
Contact Person’s Email Address:
8. If the applicant is a corporation, then provide its State of incorporation:
9. List all other locations (i.e. regional offices), providing complete addresses and telephone
numbers. (Attach a separate sheet to this application if necessary):
PO Box or Street Address:
City, State Zip:
Telephone:
PO Box or Street Address:
City, State Zip:
Telephone:
PO Box or Street Address:
City, State Zip:
Telephone:
PO Box or Street Address:
City, State Zip:
Telephone:
10. Please provide Exhibits in response to each of the following items required under 36 O.S.
6558 for private review agents, 36 O.S. 6559 for an insurance company’s in-house reviews, or
74 O.S. 1306.2 for the Oklahoma State and Education Employees Group Insurance Board.
Exhibit One: Provide the applicant’s utilization review plan, including:
An adequate summary description of review standards, protocol, and procedures to be
used in evaluating proposed or delivered hospital or medical care, and;
Assurances that the standards and criteria to be applied in review determinations are
established with input from health care providers representing major areas of
specialty and certified by the Boards of the various American medical specialties, and the
provisions by which patients or health care providers may seek reconsideration or appeal of
adverse decisions by the private review agent.
G:\DATA\SERFF\Speed to Market Initiatives\OK\License and Cert of Auth\UR Forms\UR Certification and-or Registration Application.docx
2
Exhibit Two: Provide the type and qualifications of the personnel either employed or under
contract to perform the utilization review. Please provide a list of your Oklahoma licensed
physicians required by Rule 365:10-15-5(a) or the company you contract with to satisfy this
regulation.
Exhibit Three: Provide the procedures and policies in place to ensure that a representative of the
private review agent is reasonably accessible.
In-state review agents:
Normal business hours
Toll-free telephone number
Answering machine/service available after hours
Respond to telephone messages within two working days
Out-of-state review agents:
Normal business hours
Toll-free telephone number
Answering machine/service available after hours
Respond to telephone messages within two working days
Exhibit Four: Provide the policies and procedures in place to ensure that all applicable State and
Federal laws to protect the confidentiality of individual medical records are followed.
Exhibit Five: Provide the policies and procedures in place to verify and identity the authority of
personnel performing utilization review by telephone.
Exhibit Six: Provide a copy of all materials designed to inform applicable patients and health care
providers of the requirements of the utilization review plan.
Exhibit Seven: Provide a list of the third party payers for which the private review agent is
performing utilization review in this state. Said list may be deemed confidential by the
Commissioner for the purpose of protecting competition between agents (Private Review Agent
only).
Exhibit Eight: Provide procedures in place for handling complaints by patients and health care
providers concerning utilization review.
G:\DATA\SERFF\Speed to Market Initiatives\OK\License and Cert of Auth\UR Forms\UR Certification and-or Registration Application.docx
3
Exhibit Nine: Provide procedures in place to ensure that after a request for medical evaluation,
treatment, or procedures has been rejected in whole or in part and in the event a copy of the
report on said rejection is requested, a copy of the report of the private review agent concerning
the rejection shall be mailed by the insurer, postage prepaid, to the ill or injured person, the
treating healthcare provider, or to the person financially responsible for the patient’s bill within
fifteen (15) days after the receipt of the request for the report.
NOTARY PUBLIC
STATE OF
COUNTY OF
I,
, being first duly sworn, state that I have read the within and foregoing
application and attachments and that the answers supplied by me therein are true and correct to the
best of my knowledge and belief and further that I will be familiar and comply with the Insurance Laws
of Oklahoma and the Rules of the State Insurance Commissioner in all my conduct of Utilization
Review.
___________________________________________
Signature of Applicant or Officer if a Firm
______________________________________
Notary Public
Subscribed and sworn to before me this _______ day of ___________________, 20_________.
My commission expires: ___________________________
(Seal)
G:\DATA\SERFF\Speed to Market Initiatives\OK\License and Cert of Auth\UR Forms\UR Certification and-or Registration Application.docx
4
CHECKLIST FOR UTILIZATION REVIEW
CERTIFICATION and/or REGISTRATION APPLICATION
Complete Application
Include Federal Identification Number (FEIN)
Include Contact Person Email Address
Include all Exhibits
Notarize the Application
Include a list of Oklahoma licensed physicians
Submit Application and Exhibits via SERFF along with $500.00 license fee
G:\DATA\SERFF\Speed to Market Initiatives\OK\License and Cert of Auth\UR Forms\UR Certification and-or Registration Application.docx
5
Page of 5