Form HIPMC-UR-1 "Utilization Review Registration Application Instruction" - Kentucky

What Is Form HIPMC-UR-1?

This is a legal form that was released by the Kentucky Department of Insurance - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the Kentucky Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form HIPMC-UR-1 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

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Commonwealth of Kentucky
Department of Insurance – Division of Health, Life Insurance and Managed Care
Utilization Review Registration Application Instruction
Instructions for submitting new or renewal applications. The following pages are the application for initial or renewal
of registration to conduct utilization review in Kentucky. Applicants are required to complete all sections and provide all
necessary documentation as evidence of compliance with KRS 304.17A-600 through 304.17A-615, and, as applicable,
806 KAR 17:280 and 806 KAR 17:290. The completed application and supporting documentation must be submitted in a
single Portable Document Format “PDF” document bookmarked to correspond to the sections of the application. If
multiple areas are satisfied by one policy or procedure bookmark the section of the policy or procedure for each
requirement. The electronic document shall be sent via email to the Department at DOI.UtilizationReview@ky.gov.
Contact the department to request alternative methods for submission of large documents.
The completed application and supporting documentation, accompanied by a filing fee of one thousand dollars
($1,000.00) made payable to the Kentucky State Treasurer, shall be sent to the following:
Kentucky Department of Insurance
500 Mero Street
Mail Drop: 2 SE 11
PO Box 517
Frankfort, KY 40602
Instructions for submitting changes to utilization review policies and procedures. Any proposed changes to utilization
review policies and procedures previously filed with the Department of Insurance that occur outside of the normal new
or renewal application process must be submitted for review and approval prior to implementation, in accordance with
KRS 307.17A-607(3). A filing fee of fifty dollars ($50), made payable to the Kentucky State Treasurer, must accompany
any revisions.
Please submit the changes in the following manner:
1. Complete the face sheet (Page 2 of this document) in its entirety;
a. Identify and report the specific policy and/or procedure that is being revised;
b. Report the existing language in the policy and/or procedure information and proposed change (e.g., Current language:
“8:00 a.m. to 4:30 p.m. EST”; Proposed language: “7:30 a.m. to 5:00 p.m. EST”)
AND submit both a redlined and a final copy;
c. Report the rationale for the change (e.g., hours of operation changed to promote efficiency in operations); and
2. Include an attestation on company letterhead that is signed and dated by the appropriate officer(s) of the
organization and/or legal counsel. The attestation shall include that the information and material submitted is “true and
accurate to the best of my knowledge and the applicable Kentucky statutory and regulatory requirements were
considered prior to proposing the change.”
3. All documents shall be submitted in a bookmarked electronic version via email DOI.UtilizationReview@ky.gov.
HIPMC-UR-1 09/2020
Page 1 of 7
Commonwealth of Kentucky
Department of Insurance – Division of Health, Life Insurance and Managed Care
Utilization Review Registration Application Instruction
Instructions for submitting new or renewal applications. The following pages are the application for initial or renewal
of registration to conduct utilization review in Kentucky. Applicants are required to complete all sections and provide all
necessary documentation as evidence of compliance with KRS 304.17A-600 through 304.17A-615, and, as applicable,
806 KAR 17:280 and 806 KAR 17:290. The completed application and supporting documentation must be submitted in a
single Portable Document Format “PDF” document bookmarked to correspond to the sections of the application. If
multiple areas are satisfied by one policy or procedure bookmark the section of the policy or procedure for each
requirement. The electronic document shall be sent via email to the Department at DOI.UtilizationReview@ky.gov.
Contact the department to request alternative methods for submission of large documents.
The completed application and supporting documentation, accompanied by a filing fee of one thousand dollars
($1,000.00) made payable to the Kentucky State Treasurer, shall be sent to the following:
Kentucky Department of Insurance
500 Mero Street
Mail Drop: 2 SE 11
PO Box 517
Frankfort, KY 40602
Instructions for submitting changes to utilization review policies and procedures. Any proposed changes to utilization
review policies and procedures previously filed with the Department of Insurance that occur outside of the normal new
or renewal application process must be submitted for review and approval prior to implementation, in accordance with
KRS 307.17A-607(3). A filing fee of fifty dollars ($50), made payable to the Kentucky State Treasurer, must accompany
any revisions.
Please submit the changes in the following manner:
1. Complete the face sheet (Page 2 of this document) in its entirety;
a. Identify and report the specific policy and/or procedure that is being revised;
b. Report the existing language in the policy and/or procedure information and proposed change (e.g., Current language:
“8:00 a.m. to 4:30 p.m. EST”; Proposed language: “7:30 a.m. to 5:00 p.m. EST”)
AND submit both a redlined and a final copy;
c. Report the rationale for the change (e.g., hours of operation changed to promote efficiency in operations); and
2. Include an attestation on company letterhead that is signed and dated by the appropriate officer(s) of the
organization and/or legal counsel. The attestation shall include that the information and material submitted is “true and
accurate to the best of my knowledge and the applicable Kentucky statutory and regulatory requirements were
considered prior to proposing the change.”
3. All documents shall be submitted in a bookmarked electronic version via email DOI.UtilizationReview@ky.gov.
HIPMC-UR-1 09/2020
Page 1 of 7
Commonwealth of Kentucky
Department of Insurance
Division of Health Insurance Policy and Managed Care
Utilization Review Registration Application Face Sheet
_________________________________
_______________________
Company Name
Phone No.
_________________________________
_______________________
__________________
DBA Name
Primary Contact Person
Fed. Tax ID. No.
_________________________________
__________________________________________________
Business Address
Business Address
_________________________________
Fax Number
******************************************************************************************
Check Appropriate Box
 Application for Initial or Renewal of Registration to conduct Utilization Review – Filing Fee $1,000.00
 Changes to previously approved Utilization Review Application – Filing Fee $50.00
A FILING WILL NOT BE ACCEPTED UNLESS ACCOMPANIED BY THE APPROPRIATE FEE
and
Make Check Payable to Kentucky State Treasurer
Certificate of Person Responsible for filing
I certify that I have been authorized by the board of directors or management committee of the
company or organization listed above to make this filing.
___________________________________
________________________
_________________
Name (Manual or Electronic Signature Required)
Position
Date
___________________________________
Name (Print or Type)
For Department Of Insurance Administrative Services Staff Only
Date:_____________ Amount: _______________ Check No.: ________________ Initials: ___________
HIPMC-UR-1 09/2020
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UTILIZATION REVIEW REGISTRATION APPLICATION
(Indicate non-applicable (N/A) where appropriate)
1. Primary Contact Person for questions relating to this Application
Name/Title
________________________________________________________________________
Mailing Address
__________________________________________________________________
_________________________________________________________________
Phone Number
_________________________________________________________________
Fax Number
_________________________________________________________________
E-mail Address
_________________________________________________________________
2. Type of Utilization Review Entity (check all that apply for Kentucky business)
 Insurer
 Private Review Agent for Self-Insured ERISA Plans
 Private Review Agent for an Insurer
 Limited Health Service Organization (LHSO) or private review agent for an LHSO
 Private Review Agent for Self-Insured Non-ERISA Plans
SECTION A: CORPORATE PROFILE
1. Please list name, title, phone number, and email address for the following positions:
Chief Executive Officer ________________________________________________________________
Name
________________________________________________________________
Title
Corporate Medical/Clinical Director: ____________________________________________________
Name
________________________________________________________________
Kentucky License #/Other State License #
________________________________________________________________
Telephone
HIPMC-UR-1 09/2020
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SECTION A: CORPORATE PROFILE (continued)
Please complete or answer as follows (additional pages may be added for responses).
1. Type of Entity (check all that apply)
 Corporation
 Partner
 Association
 Limited Liability Co.
 Not-For-profit
 For-profit
 Public
 Private
 Mutual
 Stock
 Other (specify) ___________________________________
2. Date of Incorporation or formation as legal entity (mm/dd/yyyy) ______________________________
3. State of Incorporation ________________________________________________________________
4. Describe the Applicant’s governing structure, including Board of Directors and standing committees,
and administration and operation of the organization. Please include an organizational chart.
5. Lines of Business (check all that apply)
Medicare
Medicaid
Indemnity
Workers’ Compensation
 Clinical specialty (specific) __________________
Utilization Management
CMO
 External Review Organization
Network
HMO
PPO
IPA
PHO/PSO
 Benefits Administration
 Home Health Care  Other: ____________________________
6. Provide the name and type of business of each corporation or other organization that the Applicant
controls or with which it is affiliated, and the nature and extent of the affiliation or control.
7. If the Applicant has delegated certain functions, please list the contracted companies, indicate which
services they perform, and provide the information requested below. If no functions have been
delegated, check “not applicable” as follows.
 Not Applicable
For each company, identify the following information:
• Name and title of contact person for the site
• Delegated site full address
• Phone and fax numbers of the contact person
• List of services provided
• A description of the oversight activities and how frequently the activities are monitored, both
on and off site (attached a copy of the subcontract agreement)
8. a. Has the Applicant ever been refused registration or certification to conduct utilization review?
YES
NO
b. If yes, please explain:__________________________________________
HIPMC-UR-1 09/2020
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SECTION A: CORPORATE PROFILE (continued)
9. a. Is the Applicant certified to perform utilization review in other states?
YES
NO
b. If yes, provide a listing of the states _________________________________________________
________________________________________________________________________________
10. a. Is the Applicant currently accredited or certified by NCQA?
YES
NO (provide current copy of certificate)
b. Check type(s) of accreditation/certification:
MCO
MBHO
COV
POC
Other-Identify________________________
11. a. Is the Applicant currently accredited in Health UM by URAC?
YES
NO (If yes, please provide a copy of the current accreditation certificate.)
b. If yes, specify type of accreditation(s):
Full
Conditional
12. Is the Applicant accredited in any other national accreditation organization?
YES
NO (If yes, please provide a copy of the current accreditation certificate.)
13.Please provide the website address where the policies and procedures and any prior authorization lists
can be viewed pursuant to KRS 304.17A-603(3) and (4).
___________________________________________________________________________________
14. Days/Hours of Operation for Kentucky business: ____________________________________________
SECTION B: ADMINISTRATION & OPERATION
Bookmark all items requested under this section with a bookmark of section B, Administration and Operation and sub-bookmarks
as identified below.
1. Agency employees. Please specify the number of employees by full-time staff, part-time staff, and consultants. Attach
curriculum vitae and job description for the Medical/Clinical Director.
Number of
Number of
Number of
Full-time Staff
Part-time Staff
Consultants
Administrative
___________________
___________________
_________________
Physicians
___________________
___________________
_________________
Chiropractors
___________________
___________________
_________________
Kentucky-licensed
___________________
___________________
_________________
Optometrists
___________________
___________________
_________________
Kentucky-licensed
___________________
___________________
_________________
Registered Nurses
___________________
___________________
_________________
Clerical
___________________
___________________
_________________
Other (Specify)
___________________
___________________
_________________
HIPMC-UR-1 09/2020
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