Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.3 - Content of an application for approval

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The application for approval of a
				  risk-assuming preferred provider organization, which is not a licensed insurer,
				  includes:
(1) A copy of the basic
				  organizational document of the applicant preferred provider organization, such
				  as the articles of incorporation, and amendments thereto.
(2) A copy of the bylaws, rules or similar
				  documents regulating the conduct of the internal affairs of the applicant
				  preferred provider organization.
(3) A list of the names, addresses and
				  official positions of members of the board of directors of the applicant
				  preferred provider organization and of persons who are responsible for the
				  conduct of the affairs of the applicant, including, but not limited to, the
				  chief executive officer, chief operating officer, director of marketing,
				  medical director and director of finance.
(4) A copy of the preferred provider
				  organization's most recent financial statement.
(5) An organization chart describing the
				  relationship between the preferred provider organization and its affiliates,
				  including the state of domicile and the primary business of each
				  entity.
(6) A description of the
				  proposed service area of the provider organization, including geographic
				  boundaries.
(7) A financial
				  analysis prepared for the purpose of determining that the proposed preferred
				  provider organization will have adequate working capital and reserves. The
				  analysis shall include a feasibility study, a business plan with projected
				  financial statements for the next 3 years, a review of proposed provider and
				  physician contracts and charges, a review of proposed rates and a market
				  opportunity analysis. The financial analysis shall be made under the direction
				  of a qualified actuary or certified public accountant.
(8) A copy of every standard form contract
				  with physicians and providers establishing preferred provider
				  arrangements.
(9) A detailed
				  description of the types of financial incentives for preferred physicians and
				  providers within the preferred provider arrangements.
(10) A list of the preferred
				  providers.
(11) A copy of
				  procedures, if any, for referral of covered persons to nonpreferred providers
				  by the preferred provider organization or a preferred provider.
(12) A detailed description of the preferred
				  provider organization's provisions to prevent undertreatment or poor quality
				  care of persons covered by the preferred provider arrangements. Standards
				  regarding the adequacy of a quality assurance system are provided in §
											152.4 (relating to scope of
				  Department of Health review of a preferred provider organization).
(13) A copy of every standard form contract
				  with health care insurers and purchasers through which preferred provider
				  arrangements are made available to covered persons.
(14) A copy of every standard form contract
				  with enrollees or groups of enrollees setting forth the preferred provider
				  organization's contractual obligations to provide, arrange for the provision of
				  or pay for covered health care services.
(15) A description of the incentives for
				  enrollees to use the services of a preferred provider contained within the
				  preferred provider organization's enrollee contracts.
(16) A copy of the preferred provider
				  organization's enrollee literature.
(17) A description of provisions within the
				  preferred provider arrangements holding covered person financially harmless for
				  payment denials by the preferred provider organizations for improper
				  utilization of covered health services caused by preferred providers.
(18) A copy of charges made to health care
				  insurers, purchasers or covered persons by the preferred provider organization
				  in consideration for establishment of the preferred provider
				  arrangements.
(19) Other
				  information that the applicant preferred provider organization may wish to
				  submit which reasonably relates to its ability to establish, operate, maintain
				  or underwrite a preferred provider organization.