Cal. Code Regs. Tit. 8, § 9771 - Applications for Certification
(a) Any of the following entities may apply
for certification as a health care organization:
(1) A disability insurer licensed by the
Department of Insurance to transact health insurance or disability income
insurance pursuant to Part 2 of Division 2 of the Insurance Code.
(2) Any workers compensation health care
provider organization.
(b) An applicant must meet all of the
requirements set forth in this article in order to be certified as a health
care organization by the administrative director. Applicants must initially
submit to the administrative director, as part of the application, a plan which
will provide a clear and concise description of how occupational medical and
health care services are to be provided and how each of the requirements in
this article are met, and, where specified, in the manner required under each
section. HCOs must include all documentation necessary to demonstrate that they
meet the requirements for certification.
(c) Health care service plans must provide
written certification that at the time of application the applicant is not in
violation of any provision of law or rules or orders of the Director of the
Department of Managed Health Care, and that there are no outstanding orders,
undertakings, or deficiency letters which involve the applicant. Disability
insurers must provide written certification that at the time of application
they are in good standing with the Department of Insurance. The requirement of
this subdivision may be satisfied by verified statement under penalty of
perjury by the president or managing officer of an applicant that the applicant
meets the requirements of this subdivision, subject to verification by the
administrative director.
(d) An
applicant who is in compliance with requirements for certification by the
Department of Insurance may submit copies of any relevant exhibits, sections or
other documents submitted as part of the primary certification application to
meet any of the requirements of this article, provided that the applicant (1)
verifies that the Department of Insurance has fully reviewed and approved the
submitted information, (2) provides a concise narrative identifying any manner
in which HCO services will be provided differently from those provided under
the primary certification, and (3) provides a concise description for each
requirement of this article, specifying how occupational medical and health
care services or other services specifically and exclusively required by this
article will be met.
(e)
Applications must be in writing in the form and manner prescribed by the
administrative director, and must be submitted on or after January 1, 1994. The
original plus one copy of the application shall be submitted together with a
fee as specified in subdivision (c). Each application shall provide, in
addition to the plan specified in subdivision (b), the following information:
(1) The names of all directors and officers
of the health care organization;
(2) The title and name of the person
designated to be the day-to-day administrator of the health care
organization.
(3) The title and
name of the person designated to be the administrator of the financial affairs
of the health care organization.
(4) The name, medical specialty, if any,
board certification, if any, and any unrestricted licenses (including states
where licensed), of the medical director.
(5) The name, address, and telephone number
of a person designated to serve as a liaison for the Division, who is
responsible for receiving compliance and informational communications from the
Division and for disseminating the same within the HCO organization.
(6) A sample of each type of contract with
participating providers, claims administrators, and insurers, and any entities
specifically providing services required by this article; and a list of
contractors for each type of contract. Copies of contracts shall be made
available to the administrative director upon request. The Division will
maintain as confidential information pertaining to provider rates and other
financial information in accordance with Government Code Section
6254(d)(1).
(7) An organizational chart demonstrating the
structural relationships between the medical director, fiscal or financial
administrator, and executive officers and administrators.
(8) The identity of any worker's compensation
insurer that controls or is controlled by the applicant, as defined by Section
1215 of the
Insurance Code.
(f) Each
application for certification must be accompanied by a non refundable fee of
$2,500.
(g) In lieu of an
application for certification, an entity licensed as a full service health care
service plan under Section
1353
of the Health and Safety Code (a Knox-Keene Health Care Service Plan Act) and
deemed to be an HCO pursuant to Labor Code Section
4600.5(c)
shall submit to the administrative director:
(1) a concise description of how the health
plan will satisfy the requirements of Labor Code Section
4600.5(c)(1
- 5) and Sections
9772 through
9778, inclusive, of these
regulations. At the time the materials required by this subsection are
submitted to the administrative director for review, the health plan shall pay
a nonrefundable documentation processing and review fee of $1,000;
and,
(2) written certification that
the health plan is not in violation of any provisions of law or rules or orders
of the Director of the Department of Managed Health Care, and that there are no
outstanding orders, undertakings, or deficiency letters which involve the
health plan. The requirements of this subdivision may be satisfied by verified
statement under penalty of perjury by the president or managing officer of the
health plan that the plan meets the requirements of this subdivision, subject
to verification by the administrative director.
Notes
2. Amendment of subsection (d), new subsection (e)(8) and amendment of subsection (f) filed 2-14-96; operative 2-14-96. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 96, No. 7).
3. Repealer of subsection (a)(1), subsection renumbering, amendment of newly designated subsection (a)(2) and subsections (c), (d) and (f), new subsections (g)-(g)(2) and amendment of NOTE filed 1-9-2003; operative 1-9-2003 pursuant to Government Code section 11343.4 (Register 2003, No. 2).
4. Amendment of subsections (f) and (g)(1) filed 11-4-2009; operative 1-1-2010 (Register 2009, No. 45).
Note: Authority cited: Sections 133, 4600.5, 4600.7, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600 and 4600.5, Labor Code.
2. Amendment of subsection (d), new subsection (e)(8) and amendment of subsection (f) filed 2-14-96; operative 2-14-96. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 96, No. 7).
3. Repealer of subsection (a)(1), subsection renumbering, amendment of newly designated subsection (a)(2) and subsections (c), (d) and (f), new subsections (g)-(g)(2) and amendment of Note filed 1-9-2003; operative 1-9-2003 pursuant to Government Code section 11343.4 (Register 2003, No. 2).
4. Amendment of subsections (f) and (g)(1) filed 11-4-2009; operative 1-1-2010 (Register 2009, No. 45).
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