Form Gid Ppa1 – Fill Out and Use This PDF

OFFICE OF

INSURANCE AND SAFETY FIRE COMMISSIONER

	Ralph T Hudgens	Seventh Floor, West Tower
	COMMISSIONER OF INSURANCE	2 Martin Luther King Jr. Dr.
		Atlanta, Georgia 30334
	SAFETY FIRE COMMISSIONER
	INDUSTRIAL LOAN	(404) 656-2056
	COMMISSIONER	WWW.OCI.GA.GOV
	COMPTROLLER GENERAL

Patient Protection Act Application for Certification

(Please file your documents in a three ring binder, with tabs separating each section in the same order as this application)

_____ 1. Name of Licensed Managed Care Entity:

___________________________________________________________________________________

___________________________________________________________________________________

(Also list type of organization, such as HMO, PSHCC, Life Insurer, Property & Casualty Insurer, etc).

_____ 2. Does your managed care entity have NCQA, JCAHO, AAHCC (URAC) or other accreditation or Certification

deemed appropriate by the Commissioner in the most recent directive issued by the Department? If yes,

include a copy of this/these certification(s) and/or accreditation and any other documentation which includes the following:

-the name of the accrediting body;

-the name and address of the accredited entity or contractor (please document relationship to such if different than applicant);

-the type of accreditation;

-the date of accreditation; and

-the expiration date of such accreditation.

If an application for accreditation is pending, submit evidence documenting receipt or pendency of such application with the accrediting body, and all of the information listed above that is applicable.

_____ 3. Does the Utilization Review organization or function used with the managed care plan have certification

by the Commissioner as required for Private Review Agents, under O.C.G.A Chapter 33-46, and Rule Chapter 120-2-58? Please document by submitting the name of entity as it appears on its Private Review

Agent Certificate or deeming notice.

Please document whether or not the utilization review program is internal to the managed care entity, or if it is subcontracted totally or in part to a managed care contractor, for all managed care plans.

If not, is there a Private Review Agent application for certification currently pending? On what date was it filed with the Office of Commissioner of Insurance.

_____ 4. Document all Managed Care Plans (specific products) for which the licensed managed care entity seeks

certification. List each form number, date approved and type of form (HMO contract, Point-of-Service, PPO w/gatekeeper, PPO without gatekeeper, PSHCC contract, Other -please describe).

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_____ 5. List any medical groups, Hospitals, IPAs, TPAs, Private Review Agents , etc. with which you have

subcontracting arrangements.

_____ 6. If you plan to have a marketing territory for managed care products which differs from the service area,

please provide documentation on the rationale for this for each product. If not, please certify such.

STANDARDS FOR CERTIFICATION

DISCLOSURE TO ENROLLEES AND PROSPECTIVE ENROLLEES

(If you are licensed as an HMO under Chapter 21, go to number 8)

_____ 7. Indicate for each Standard of Certification contained in 33-20A-5(1)(A) where and how such information

is disclosed (either in your policy or certificate, outline of coverage, marketing materials, provider directory, member handbook, etc). Include how you will comply with both initial and annual disclosure.

(For each policy presented for review as part of this application, please reference the form number, page number, and line number(s) where each condition is met.)

_____ 8. Every certificate and policy must state the managed care entity's commitment to treating enrollees in a

manner that respects their rights, security and privacy as well as its expectations of their responsibilities. Please document that your policies and certificates disclose the enrollee's right to:

A.Receive medically appropriate care in a timely and convenient manner;

B.Participate in decision making regarding treatment, care and services;

C.Receive information about the plan, services and providers;

D.Voice complaints or request appeals and have them addressed in a timely manner; and

E.Have a family member or designated person facilitate any care when the enrollee is unable to do so.

Please document that your policies and certificates disclose the enrollee's responsibilities to:

F.Provide necessary information to facilitate effective medical care;

G.Cooperate with health care providers by keeping appointments and following recommended treatment; and

H.Follow the health plan's rules and regulations.

ACCESS TO SERVICES

Managed care entities shall maintain a network that is sufficient in numbers and types of providers to assure that all required services will be accessible without unreasonable delay and include the following:

_____	9.	A.	Identification of the proposed service area ( include counties and zip codes);
		B.	A map showing participating providers ( primary and specialty if appropriate) in the proposed
			geographic area; and
		C.	The total number of available hospitals in each county you service and the number of hospitals
			that participate in your plan in those counties.
_____	10.	Submit a written access plan outlining your strategy for developing and maintaining an adequate network
		and your process for monitoring and assuring on an ongoing basis the sufficiency to meet the needs of
		the population enrolled in each managed care plan by addressing:

A.Proposed enrollee ratios by primary care and specialty providers;

B.Number of primary care providers not accepting new patients;

C.Proximity of providers to enrollee's home or place of business; and

D.Expectation standards for participating physicians regarding waiting times and appointment scheduling.

_____ 11. Outline your methods of informing enrollees of the plan's process for choosing and changing providers .

_____ 12. Please answer in detail the following, and include all relevant policies and procedures :

A.What are your procedures for providing emergency and urgent care services within and outside the managed care entity's service area?

B.How does your plan provide for medically necessary covered services 24 hours a day and seven days a week?

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_____	13.	Describe, where applicable, your written policies			for:
		A.	Making referrals within and outside of your		network;
		B.	Accommodating specialty provider insufficiencies; and
		C.	Assuring the accommodation and continuity of care for enrollees referred to specialty physician or
			for ancillary services.
_____	14.	What procedures do you have in place for monitoring timeliness of member services responses to
		enrollees= requests for information.
		A.	Where is your member services department located?
		B.	What are your standards for handling incoming calls from members:
			(i)	during regular business hours; and
			(ii)	after regular business hours?
_____	15.	In the event of contract termination between the managed care entity and the participating provider,
		how will continuity of care and notification of the members be handled?
		Document that you have hold harmless or other provisions regarding providers and their medical and

financial treatment of enrollees in the event the managed care entity has financial difficulty.

QUALITY ASSURANCE PROGRAM

_____ 16.

The quality assurance program should be administered by a qualified committee, supervised by the medical director with representation by an appropriate base of providers and support staff. Please outline your program by including the following:

A.Identify the members along with their qualifications and responsibilities who manage and participate in the program.

B.To whom is the quality assurance program accountable?

_____ 17. Submit policies and procedures which identify the mechanism for credentialing and recredentialing.

Include but do not limit documentation to written descriptions of the following:

A.Members and qualifications of credentialing committee;

B.Verification of provider information;

C.Procedure for and frequency of physician office site visits;

D.Recredentialing decision making process, including standards for evaluation of provider performance;

E.Provider disciplinary actions, termination and appeal procedures;

G.Oversight of any delegated credentialing activities; and

H.Policies and procedures for initial and ongoing assessment of organizational providers (hospitals, home health agencies and clinics etc).

_____ 18. Ongoing quality assurance procedures should include defined methods for the identification, evaluation,

resolution and follow up of potential and actual problems to include clinical issues, health care administration and delivery of service with input from multiple sources. Outline your quality assurance

methodologies including but not limited to the following:

A.Defining the scope and content of the program as well as the roles and responsibilities of the individuals involved;

B.Methods and sources used for identification of potential and actual problems;

C.Stressing health outcomes consistent with current medical research, knowledge, standards and practice guidelines;

D.Consideration of demographic groups in the plan, care settings and types of service;

E.Focus of review ( high volume, high risk, diagnosis or procedure or other problems); and

F.Evaluation of overall effectiveness of the program.

_____ 19. Provide documentation that the information system is capable of collecting and aggregating enrollee

information to identify patterns such as under-utilization and over-utilization, adverse outcomes or substandard care.

_____ 20. Explain your process for determining member satisfaction to include:

A.Surveying the enrollee's satisfaction with the health care plan;

B.Evaluating enrollee complaints and grievances;

C.Monitoring requests to change physicians ; and

D.Review of voluntary plan disenrollments.

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_____ 21. A managed care entity that conducts utilization review must implement a program that describes all

review activities both delegated and non-delegated. Outline your program to include:

A.Staff position functionally responsible for day to day program management;

B.Data sources and clinical review criteria used in determining the clinical necessity and appropriateness of health services;

C.Data collection process and analytical methods used;

_____ 22. Describe your complaint, appeal and grievance processes to include but not limited to:

A.Written procedures of how complaints will be handled to include the timeliness of notification to enrollees and tracking of complaints by specific categories;

B.Examples of what constitutes an appealable situation;

C.Levels available and proposed time frames to be used in resolving standard appeals;

D.Criteria used in determining the necessity for offering an expedited appeal process; and

E.Implementation of the grievance procedure following a request for additional review after a final appeal which resulted in an adverse determination.

FINANCIAL INCENTIVE PROGRAMS

_____	23.	Demonstrate separation of medical services from fiscal management sufficient to assure that medical
		decisions will not be inappropriately influenced by fiscal management.
_____	24.	Submit copies of sample provider contracts which include methods of provider reimbursement, options
		regarding provider reimbursement, and a certification within the terms of the provider contract that no
		financial incentive program exists that directly compensates a health care provider for ordering or
		providing less than medically necessary and appropriate care to his or her patients.
DISCUSSION OF PATIENT=S CARE
_____	25.	Disclose policies and procedures assuring that no health care provider will be penalized for discussing

medically necessary or appropriate care with or on behalf of his or her patient.

CONFIDENTIALITY AND RECORDS MAINTENANCE

_____ 26.

Member information must be kept confidential in accordance with applicable federal and state laws. Written procedures should be in place outlining;

A.Which individuals and agencies have authority to receive member information;

B.Efforts to safeguard the privacy of individual enrollee information at all levels within the managed care entity;

C.Documentation required for each provider/enrollee encounter.

EMERGENCY STABILIZATION

_____ 27.	What criteria and procedures are used by your managed care entity for determination of coverage of
	emergency services and transportation of enrollees to alternate facilities in compliance with O.C.G.A. ∋ 33-
	20A-9(1)(A) - (C). How is this information relayed to both enrollees and providers?

RESTRICTIVE FORMULARY

_____ 28.	Does your managed care plan have a restrictive formulary? If so, please explain your procedures
	whereby an enrollee may obtain prescription drugs and medication outside of the formulary.

The Following items must be attached:

_____	29.	Member and Provider Handbooks
_____	30.	Provider Directory
_____	31.	Proposed Enrollee Survey
_____	32.	Sample Provider Contracts

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Upon initial review of these application filings, the Commissioner may require additional information or filings to support the application for admission. (See Georgia Insurance Regulation 120-2-80)

Note: Application is INCOMPLETE until ALL items have been filed in their entirety.

CERTIFICATION OF CONTENTS BY INSURER

Please provide a certification from an appropriate officer of the managed care entity that all documents submitted here within are true and accurate in the following format:

Certification

I do solemnly swear or affirm that I am familiar with and agree to abide by with the Laws of Georgia relating to the Patient Protection Act under the requirements of O.C.G.A. Chapter 33-20A, and Rule 120-2-80 and that all the foregoing information and documentary evidence submitted is true, complete, and correct to the best of my knowledge and belief. I understand that my certification is subject to administrative action if false information is contained herein.

__________________________________________________

Insurer
__________________________________________________
Signature of Affiant
__________________________________________________
Name (typewritten)
	Sworn to and subscribed before me
__________________________________________________	Title (typewritten)
	this ____ day of__________ , 20 ______
________________________________________________
	(Notary Public)

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