Description of application form

Each application for a certificate shall be accompanied by a non-refundable filing fee. The filing fee shall be the fee set in the Act. The fee shall be paid by check to the Oklahoma State Department of Health. OAC 310:657 OKLAHOMA STATE DEPARTMENT OF HEALTH (1) The application for a certificate requests the following: (A) A general description of the Plan and its operations, including the locations, types, and hours of providers; (B) A copy of the Plan's basic organizational document, such as the articles of incorporation or association, partnership or trust agreement, and all amendments; (C) A copy of bylaws or similar document, regulating the Plan's conduct; (D) A list of names, addresses, and official capacities of all persons responsible for the Plan, including: (i) Each corporate officer and director of a corporation; each manager of Limited Liability Company; those owners of a corporation, the partners or associates of a partnership or association, or members of a Limited Liability Company that own five percent (5%) or more of the stock or controlling interest in the Plan, Corporation, Partnership, Association, or Limited Liability Company; and of the person who will be the day- to-day Plan administrator; and (ii) Disclosure of any contracts or arrangements between them and the Plan, including any appearance of a conflict of interest; (E) The medical director's name, address, phone number, Oklahoma license number, and biographical information and address; (F) The name and biographical information of the person who will be the day-to-day Plan administrator and address; (G) A description of the geographic areas to be served; (H) A description of any facilities to be used; (I) The categories and names of all participating providers and facilities; (J) The policies for credentialing and selection of providers; (K) Projections for five (5) years which include employee population, primary physician to employee ratios, specialty care, laboratory, x-ray and hospital services, and revenues and expenses; (L) A financial statement for the Plan prepared in accordance with accounting principles generally accepted in the United States of America, and related documents showing the Plan's financial capabilities; (M) Forms of all provider and service contracts; (N) Forms of all contracts with insurers and insureds, showing the services to which employees are entitled; (O) Proposed marketing or advertising materials; OAC 310:657 OKLAHOMA STATE DEPARTMENT OF HEALTH (P) Descriptions of the case management, utilization review and quality assurance processes, including treatment protocols, adopted by the Plan; (Q) A description of the Plan's or providers' medical record system; (R) Policies for developing and reporting data; (S) Policies for dispute resolution and grievance reviews; (T) A plan for an employee education program; (U) A description of the financial incentives to be used to reduce costs and control use; (V) A description of the Plan's workplace health and safety consultative services for employers; (W) The provider directory; (X) Contact person's name, address and telephone number; and, (Y) Such other information as may be prescribed by the Commissioner in the application for a certificate. (2) The application to renew a certificate requests the following: (A) Any changes in the information provided in OAC 310:657- 21-4; and (B) Data on the Plan's experience, including revenues and expenses, changes in financial position, employee population per month, hospital days and ambulatory encounters per injured worker, encounters by type of health professional, disputes and grievances processed, peer review, quality control, medical records and utilization review systems. (3) The Commissioner may require such other information as necessary to decide on the application. SUBCHAPTER 23. APPROVAL OR DENIAL OF APPLICATION