Fill and Sign the Application for Certification of Managed Care Plan State of Form

South Dakota Department of Labor Kneip Building, Third Floor 700 Governors Drive Pierre, South Dakota 57501-2277 APPLICATION FOR CERTIFICATION OF MANAGED CARE PLAN ____________________________________________________________ Use this form to certify your m anaged care plan as required by SDCL 58- 20-24, 62-5-21, and ARSD chapter 47:03:04. Answer completely the following questions about your managed care plan. If more space is needed, use additional pages (identify your response with the question number). Any supporting documents should be attached to this application. Please return the application by September 30 of the current calendar year. If you have any questions about the information requested, please call (605) 773-3681. ____________________________________________________________ 1. What is your company's name and the address of the place of business where the plan will be administered and records kept? No plan will be certified without a South Dakota place of business. 2. In what state is your company incorporated and what is the date of incorporation? 3. What is the name, address, and phone number of a contact person for the managed care plan? 4. What is the name, title, and c redentials of the day-to-day administrator of the plan? 1 OF 7 5. What are the names and addresses of the officers or directors of the plan or the company that owns the plan? 6. Does your company operate a managed care, utilization review, or case management business outside South Dakot a? If yes, list the states in which you operate such a business and indicate whether the business is certified by any organization or government agency. 7. What are the names and credentia ls of the individuals who will be making final utilization review or medical case management decisions for the plan? The individuals must be lic ensed, registered, or certified health care providers under SDCL title 36. 8. Will you use a network of participating medical practitioners? If you answered question 8 "Yes," answer questions 9, 10, and 11. If you answered question 8 "No," answer question 12. 9. What are the names, addresses, and specialties of all participating medical practitioners who will provide services under the managed care plan? Attach a statement declaring that the practitioners have complied with any licensing or certification requirements to practice in South Dakota. 10. What are your procedures to ensure each participating medical practitioner meets the licensing and certification requirements to practice in South Dakota and to exclude a practitioner whose license is under suspension or has been revoked by the licensing board. 11. Attach a copy of the standard agreement that participating medical practitioner’s sign. What other arrangements will you have with medical practitioners to deliver services to employees? 2 OF 7 12. What arrangements will you have with medical practitioners to deliver services to employees under your plan since you do not have a provider network? 13. How will you provide employees prompt and convenient access to health care services as required by ARSD 47:03:04:04? Specifically, how will you make sure employers promptly notify the plan about injuries and employees receive prompt treatment when they request treatment from the plan? What are your procedures for referring an employee to an outside medical practitioner when services are unavailable or are not reasonably accessible within the plan? 14. How will your plan authorize necessary medical services provided by an outside medical practitioner as required by ARSD 47:03:04:05 and 47:03:04:06? Specifically, how will y ou work with a medical practitioner initially selected by an employee and make sure the medical practitioner complies with the provisions of the rules and the plan? How will you handle emergency treatment? What are your procedures for approving referrals for other treatment or before diagnostic testing? 15. How will you comply with ARSD 47:03:04:07, which prohibits discrimination against or exclusion from participation in the plan of any category of medical practitioner? 16. Attach the treatment standards your plan has developed to use in reviewing medical services. No plan will be certified without comprehensive treatment standards dev eloped for worker's compensation injuries that have been reviewed and approved by the department. What is the source of your treatment standards? How will the treatment standards 3 OF 7 be used to review medical services to ensure services are necessary and appropriate? 17. What are your methods of utilization review to prevent inappropriate, excessive, or medically unnecessary medical services? Explain any pre-authorization requirements, concurrent review, or retrospective review that is part of your utilization review program. 18. What are your procedures for excluding medical practitioners who violate your treatment standards from participating in the plan? 19. How will you develop a treatment plan, monitor the treatment and medical progress of the employee, and make sure that the employee is following the treatment plan? 20. How will you develop a plan f or promptly returning an employee to work? 21. How will you provide for cooperative efforts by employees, employers, and the managed care plan to promote workplace health and safety? 22. How will individuals receive prompt information and advice on the medical services available from your plan and how to access those services on a 24-hour basis using your toll-free telephone service? 4 OF 7 23. What are your procedures for reporting to the employer at least once a month on the medical status and return-to-work status of an employee? 24. What are your procedures for informing medical practitioners of the applicable treatment standards of the plan? 25. What other methods will you use to communicate to employees, employers, and medical practitioners the services and requirements of your plan? Attach or describe any written material that will be used as part of your communication program. 26. What are your plan's internal dispute resolution procedures, including methods to promptly resolve complaints by employees, medical practitioners, employers, and insurers? How will you notify individuals of decisions made by your plan and the procedures for disputing those decisions? 27. How will you record and report to the department information regarding medical service costs and utilization and regarding other necessary information as require by ARSD 47:03: 04:09? Please explain how you will maintain the required records and describe any additional information you will supply in your annual report that will assist the department in determining the effectiveness of your plan. 28. How will you ensure continuity of care when an insurer's contract with a managed care plan terminates or a contract between the managed care plan and a participating medical practitioner terminates? 5 OF 7 29. What are your methods for ensuring quality control in the delivery of managed care services? Please send the original of this application to: South Dakota Department of Labor Kneip Building, Third Floor 700 Governors Drive Pierre, SD 57501-2277 Please attach to the application a copy of the following:  The standard agreement that participating medical practitioners sign (if applicable);  A statement declaring the medical practitioners have complied with any licensing or certification requirements to practice in South Dakota (if applicable);  The treatment standards the plan has developed to use in reviewing medical services; and  Any written materials the plan will use as part of its communication program. The applicant, by its authorized corporate officer:  Authorizes the department to audit or investigate the accuracy of any statement made in this application and related documents;  Agrees to assist the department in conducting the audit or investigation; and 6 OF 7  Agrees to allow the department access to its place of business and to information and record requested by the department. 7 OF 7 The applicant understands and agrees that if a material fact in this application or related documents has been misrepresented or if the managed care plan no longer meets the requirements of the law and administrative rules, the department may deny or may suspend or revoke the certification of the managed care plan under ARSD 47:03:04:11. ____________________________________________________________ APPLICANT NAME APPLICANT SIGNATURE DATE SIGNED