"Application for Certificate to Transact Business as a Utilization Review Agent" - Nebraska

Application for Certificate to Transact Business as a Utilization Review Agent is a legal document that was released by the Nebraska Department of Insurance - a government authority operating within Nebraska.

Form Details:

  • Released on November 1, 2019;
  • The latest edition currently provided by the Nebraska Department of Insurance;
  • 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 Nebraska Department of Insurance.

ADVERTISEMENT
ADVERTISEMENT

Download "Application for Certificate to Transact Business as a Utilization Review Agent" - Nebraska

142 times
Rate (4.8 / 5) 9 votes
REQUIREMENTS AND PROCEDURE FOR OBTAINING AN
UTILIZATION REVIEW AGENT’S CERTIFICATE
RESIDENT AND NONRESIDENT
A utilization review agent may not conduct utilization review upon a covered person in this state unless
the agent is granted a certificate by the director. Certificates granted under the Utilization Review Act
shall be valid for two years from the date of issuance.
PROCEDURE
1) Submit Form DOI URA - Application for Certification to Transact Business as a
Utilization Review Agent.
2) Also include the following documentation with the application:
a) Documentation that the applicant has received approval or accreditation by the American
Accreditation HealthCare Commission/URAC, or a similar organization which has standards for
utilization review agents that are substantially similar to the standards of the American
Accreditation HealthCare Commission/URAC, and which has been approved by the director;
b) A list of the principal officers of the entity responsible for its operation, management, and
control (page two of paper application).
3) Submit application fee.
LICENSE FEES – UTILIZATION REVIEW AGENT
Initial Fee…………………………………………………………………………. $300.00
Two-Year Renewal Fee ………………………………………………..….. $100.00
Reinstatement Fee ………………………………………………..………… $300.00
*Checks should be made out to the Nebraska Department of Insurance.
PRINTING LICENSES
The Nebraska Department of Insurance Licensing Division no longer mails out a hard copy of new or
renewed licenses. A copy of your license can be downloaded or printed by going to:
https://sbs.naic.org/solar-external-lookup/license-manager.
DURATION OF LICENSE
Utilization review certificates are valid for two (2) years from the date they are issued. Certificates
expire one day prior to the two year anniversary of the issue date.
LICENSE RENEWAL
Certificates may be renewed ninety (90) days prior to their expiration date by submitting the following
to the Nebraska Department of Insurance:
1) Renewal fee of one hundred dollars ($100).
2) A statement detailing any changes in the information or documentation that was filed with the
initial application.
DOI-URA
Rev. 11/2019
REQUIREMENTS AND PROCEDURE FOR OBTAINING AN
UTILIZATION REVIEW AGENT’S CERTIFICATE
RESIDENT AND NONRESIDENT
A utilization review agent may not conduct utilization review upon a covered person in this state unless
the agent is granted a certificate by the director. Certificates granted under the Utilization Review Act
shall be valid for two years from the date of issuance.
PROCEDURE
1) Submit Form DOI URA - Application for Certification to Transact Business as a
Utilization Review Agent.
2) Also include the following documentation with the application:
a) Documentation that the applicant has received approval or accreditation by the American
Accreditation HealthCare Commission/URAC, or a similar organization which has standards for
utilization review agents that are substantially similar to the standards of the American
Accreditation HealthCare Commission/URAC, and which has been approved by the director;
b) A list of the principal officers of the entity responsible for its operation, management, and
control (page two of paper application).
3) Submit application fee.
LICENSE FEES – UTILIZATION REVIEW AGENT
Initial Fee…………………………………………………………………………. $300.00
Two-Year Renewal Fee ………………………………………………..….. $100.00
Reinstatement Fee ………………………………………………..………… $300.00
*Checks should be made out to the Nebraska Department of Insurance.
PRINTING LICENSES
The Nebraska Department of Insurance Licensing Division no longer mails out a hard copy of new or
renewed licenses. A copy of your license can be downloaded or printed by going to:
https://sbs.naic.org/solar-external-lookup/license-manager.
DURATION OF LICENSE
Utilization review certificates are valid for two (2) years from the date they are issued. Certificates
expire one day prior to the two year anniversary of the issue date.
LICENSE RENEWAL
Certificates may be renewed ninety (90) days prior to their expiration date by submitting the following
to the Nebraska Department of Insurance:
1) Renewal fee of one hundred dollars ($100).
2) A statement detailing any changes in the information or documentation that was filed with the
initial application.
DOI-URA
Rev. 11/2019
NOTIFICATION OF CHANGES
A utilization review agent shall notify the director within five working days of any change of the agent's
approval or accreditation status or of any material change in the information contained in the agent's
application or renewal or that the agent no longer meets the requirements of the
Utilization Review Act.
For further information regarding the rules and requirements for obtaining the Utilization Review
Agent’s Certificate please see
Neb.Rev.Stat
44-5416.
Reasonable accommodations for disabled persons available
upon request at (402) 471-2201. TDD users 800-833-7352 for relay to (402) 471-2201
NEBRASKA DEPARTMENT OF INSURANCE
INSURANCE LICENSING DIVISION
P.O. BOX 82089
LINCOLN, NE 68501-2089
E-mail: DOI.Licensing@Nebraska.gov
Licensing Division: (402) 471-4913
DOI Main Line: (402) 471-2201
Toll Free: (833) 410-5609
Fax: (402) 471-6559
DOI-URA
Rev. 11/2019
STATE OF NEBRASKA
For DOI Use Only
DEPARTMENT OF INSURANCE
Identifier # ______________
PO Box 82089
Amount ________________
Lincoln, NE 68501
Dist # _________________
www.doi.nebraska.gov
Check # ________________
MOTOR CLUB REPRESENTATIVE
APPLICATION FOR CERTIFICATE TO TRANSACT BUSINESS
AS A UTILIZATION REVIEW AGENT
TYPE OF ENTITY
Please check one:
Corporation
Partnership
Other ____________________________
(Please Specify)
Business Entity Name: ______________________________________________________________________
Federal I.D. # _________________________________
Date Incorporated _________________________
Business Address: __________________________________________________________________________
Street Address
___________________________
______
_____________
____________________________________
City
State
Zip Code
Phone
Mailing Address: __________________________________________________________________________
Street Address
___________________________
______
_____________
____________________________________
City
State
Zip Code
Business Email
Which classes or types of insurance will the applicant be conducting in Nebraska?
__________________________________________________________________________________________
(Please Specify)
Please submit with the application, proof that you have received approval or accreditation by the Utilization
Review Accreditation Commission, Inc. or NCQA. Please also include a $300.00 check for the license
application fee.
Application and fees can be submitted to the Department at the address information below:
NEBRASKA DEPARTMENT OF INSURANCE
INSURANCE LICENSING DIVISION
P.O. BOX 82089
LINCOLN, NE 68501-2089
E-mail: DOI.Licensing@Nebraska.gov
Licensing Division: (402) 471-4913
DOI Main Line: (402) 471-2201
Toll Free: (833) 410-5609
Fax: (402) 471-6559
Page 1 of 2
DOI-URA
Rev 11/2019
Business Entity Name: ____________________________________________________________
List below the principal officers responsible for the operations, management and control of
the applicant name herein:
Officer 1
Name:
Title:
Business Address:
Resident Address:
Social Security Number:
Officer 2
Name:
Title:
Business Address:
Resident Address:
Social Security Number:
Officer 3
Name:
Title:
Business Address:
Resident Address:
Social Security Number:
Officer 4
Name:
Title:
Business Address:
Resident Address:
Social Security Number:
This application must be signed by all named principle officers listed above.
Officer 1: ________________________________________________
____________________
Signature
Date
Officer 2: ________________________________________________
____________________
Signature
Date
Officer 3: ________________________________________________
____________________
Signature
Date
Officer 4: ________________________________________________
____________________
Signature
Date
Subscribed to in my presence and duly sworn this __________ day of ____________________,
20______.
________________________________________
Notary Public
Page 2 of 2
DOI-URA
Rev 11/2019
Page of 4