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

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

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

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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
ANNUAL RENEWAL APPLICATION
This completed Application and all applicable Exhibits must be submitted via SERFF. The Renewal 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. Oklahoma Certificate of Registration Number:
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:
7. Contact Person:
Contact Person Telephone Number:
Contact Person Email Address:
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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
ANNUAL RENEWAL APPLICATION
This completed Application and all applicable Exhibits must be submitted via SERFF. The Renewal 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. Oklahoma Certificate of Registration Number:
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:
7. Contact Person:
Contact Person Telephone Number:
Contact Person Email Address:
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8. If 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. Attach a list of any and all review agents that the company will use. Provide updates of review
agents as they are added or dropped, including dates. 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.
11. Please review your previous application. Resubmit any Exhibits that have changed since your
previous application was submitted. Indicate below any exhibits being resubmitted. Also,
Exhibit Eleven should be included with each renewal.
Exhibit One: Provide the applicant’s utilization review plan, including:
An adequate summary description of review standards, protocols 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 various American medical specialties, and;
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The provisions by which patients or health care providers may seek reconsideration of
appeal of adverse decisions by the private review agent.
Exhibit Two: Provide the type and qualifications of the personnel either employed or under
contract to perform the utilization review.
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 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 to verify the identity and 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 all the requirement of the utilization review plan.
Exhibit Seven: Provide a list of 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 Agents only.)
Exhibit Eight: Provide the procedures for receiving and handling complaints by patients and health
care providers concerning utilization review.
Exhibit Nine: Provide procedures 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
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rejections is requested, a copy of the reports of a private review agent concerning the rejection
shall be mailed by the insurer, postage prepaid, to the ill or injured person, the treating health care
provider, or to the person financially responsible for the patient’s bill within fifteen (15) days after
receipt of the report.
Exhibit Ten: Provide your policy and procedures to establish and maintain a complaint system for
the resolution of written complaints concerning utilization review.
Exhibit Eleven: Provide a summary report of all complaints filed during the past year. Also note
that 36 O.S. 6560(B)(5) requires your company to maintain records of complaints for five years
from the time of complaint.
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)
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CHECKLIST FOR UTILIZATION REVIEW RENEWAL APPLICATION
Complete Renewal Application
Include Federal Identification Number (FEIN)
Include Contact Person Email Address
Resubmit any Exhibits that have changed since your previous application was submitted
Include list of Oklahoma licensed physicians
Include Exhibit Eleven with this renewal application
Notarized the Application
Submit Application and Exhibits via SERFF along with $500.00 renewal fee
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