"Certified Organized Delivery System (Ods) Annual Report" - New Jersey

Certified Organized Delivery System (Ods) Annual Report is a legal document that was released by the New Jersey Department of Banking and Insurance - a government authority operating within New Jersey.

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  • Released on December 31, 2020;
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STATE OF NEW JERSEY
Department of Banking and Insurance
Certified Organized Delivery System (ODS)
Annual Report
_______________
Name of ODS
December 31, 2020
Year Ending
This report may be submitted to the Department by mail or electronically. Please submit a
completed report to the address below:
Barbara Hanlon
Supervising Healthcare Evaluator
New Jersey State Department of Banking and Insurance
Office of Managed Care
P. O. Box 329
th
20 West State Street, 9
Floor
Trenton, New Jersey 08625-0329
Fax: 609-633-0807
Email:
Barbara.Hanlon@dobi.nj.gov
Thank you for your cooperation.
STATE OF NEW JERSEY
Department of Banking and Insurance
Certified Organized Delivery System (ODS)
Annual Report
_______________
Name of ODS
December 31, 2020
Year Ending
This report may be submitted to the Department by mail or electronically. Please submit a
completed report to the address below:
Barbara Hanlon
Supervising Healthcare Evaluator
New Jersey State Department of Banking and Insurance
Office of Managed Care
P. O. Box 329
th
20 West State Street, 9
Floor
Trenton, New Jersey 08625-0329
Fax: 609-633-0807
Email:
Barbara.Hanlon@dobi.nj.gov
Thank you for your cooperation.
STATE OF NEW JERSEY
Department of Banking and Insurance
Certified Organized Delivery System (ODS)
Annual Report
ODS: _________________________________________________________________________
Contact Person for
Annual Report:
________________________________________________________________
Name
Telephone
E-mail
1. Identify the services provided by the ODS on behalf of carriers:
[ ] Network Management, including credentialing/ recredentialing and provider complaints
[ ] Utilization Management Development
[ ] Utilization Management Application
[ ] Utilization Appeals: _____ Stage 1 only _____ Stage 1 and Stage 2
[ ] Member Complaints
2. Complete the chart below identifying each carrier under contract with the ODS and the number of
covered lives per carrier for business in New Jersey. If the services performed by the ODS differ
by carrier, identify the specific services performed for each carrier.
Number of Covered
Commercial
Medicaid
Carrier
Lives
3. List all of the states in which the ODS is doing business:
______________________________________________________________________________
CODS Annual Report Year Ending 12/31/2020
1
Name of ODS: _________________________________
4. Submit a current organizational chart, identifying the names and titles of the persons responsible
for the conduct of the affairs of the ODS. Include the ODS’s principal officers and medical
director, if applicable.
5. Submit a copy of the ODS’ Continuous Quality Improvement Work Plan and Evaluation.
6. During the past year, has the ODS, its affiliates, or persons who are responsible for the conduct of
the ODS or affiliates been subject to any administrative, civil or criminal actions and proceedings.
If yes, provide a list of the actions and a statement regarding the resolution of such actions.
YES ______
No ________
7. During the past year, has the ODS, or any of its affiliates, failed to meet a carrier’s performance
measure(s) or been penalized by a carrier? If yes, provide a list of the performance measure(s)
and/or penalties.
YES _______
NO _______
8. During the past year, has the ODS been required to submit a Plan of Correction (POC) to a
carrier? If yes, provide a list of each POC including the date, brief description of the corrective
action and confirm that the POC was accepted by the carrier.
YES ________ NO _______
Changes in Operations
Pursuant to N.J.A.C. 11:24B-2.7 (a) except as set forth in N.J.A.C. 11:24B-2.6, an ODS shall
provide the Department with 30 days prior notice of changes to information contained in its
certification unless 30 days’ prior notice was impossible, in which event, the ODS shall provide
notice of the change as soon as possible, but within no more than 30 days following the date of the
change. Please identify any change in operations not reported to the Department during 2020.
Certification
As an Officer of the ODS, I certify that all information submitted in this Annual Report gives a full
and true statement of the condition of the ODS, according to the best of my information, knowledge
and belief. This also certifies that all changes for 2020 as described by N.J.A.C. 11:24B-2.7 have
been reported.
Name of CEO
Signature
Date
CODS Annual Report Year Ending 12/31/2020
2
Name of ODS: _________________________________
Network Management
I. Network
1. Approved counties: [
] All 21 NJ counties
[
] Less than 21 counties*
*If not approved in all 21 counties, identify the names of the counties for which approval
has not been obtained: ____________________________________________________
2. Submit current network information using the applicable network tables available at
http://www.state.nj.us/dobi/division_insurance/managedcare/mcapps.htm
3. Explain how the ODS maintains and monitors the network of contracted providers to ensure
network adequacy. (Attach a separate page)
4. The following questions pertain to the formation of the network via contracting:
a. Are all providers represented as being in the network under direct contract with the ODS?
YES ______
NO*______
*If no, explain how the network is formed and identify the contracts the ODS has
entered into for purposes of network formation. Specify whether the ODS maintains
responsibility for credentialing these providers? (Attach separate page)
II. Provider Directory
5.
Provide the web address of the on-line provider directory, if available to covered persons:
______________________________________
6. Explain the process for maintaining a current and accurate listing of network providers.
Include in the explanation, how frequently provider data information is verified and a
description of the verification process.
Note: This question must be answered regardless of whether the ODS publishes its own
directory or the ODS network is incorporated into the carrier’s directory.
CODS Annual Report Year Ending 12/31/2020
3
Name of ODS: ______________________________
III. Provider Complaints
7. Report the total number of provider complaints received during the past year for each carrier
contract. Identify the top three (3) categories of provider complaints:
Number of
CARRIER
Complaints
Complaint Categories
8. Is provider complaint data reported to carriers?
YES ______ NO _____
If yes, include a copy of the data reported to carriers for the most recent year.
IV. Provider Relations
9. Submit a copy of the most recent provider satisfaction survey and the results for each carrier.
Identify the number of providers who were sent a survey and the number of providers who
responded.
CODS Annual Report Year Ending 12/31/2020
4