Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 21 - Applying for a Certificate › Section 310:657-21-4 - Description of application form

Current through Vol. 41, No. 20, July 1, 2024
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.
(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;
(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.