Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter G - HMOS › APPLICATION FOR CERTIFICATE OF AUTHORITY › Section 9.631 - Content of an application for an HMO certificate of authority

Current through Register Vol. 54, No. 28, July 13, 2024
An application for a certificate of authority under the
						HMO Act shall include completed application forms as the Secretary and
						Commissioner may require. An application for a certificate of authority will
						not be deemed complete unless it includes at least the following
						information:
(1) Organizational
					 information including a copy of the applicant's articles of incorporation,
					 bylaws that include a description of the manner by which subscribers will be
					 selected and appointed to the board of directors, an organization chart and
					 clear disclosure of the relationship between the applicant and any affiliated
					 entities owned or controlled by the applicant or which directly or indirectly
					 own or control the applicant.
(2) A
					 list of names, addresses and official positions of the board of directors of
					 the applicant, and of persons who are responsible for the affairs of the
					 applicant, including: president/chief executive officer; medical director;
					 chief financial officer; chief operating officer; directors of quality
					 assurance, UR, provider relations, member services; and the director of the
					 enrollee complaint and grievance process if this responsibility does not fall
					 under one of the previous directorships listed. Resumes shall be included for
					 chairperson of the board and the positions listed in this paragraph.
(3) The address of the registered office, in
					 this Commonwealth, where the HMO can be served with legal process.
(4) A copy of each proposed standard form
					 health care services provider contract and each standard IDS contract including
					 a detailed description of the reimbursement methodologies and types of
					 financial incentives that the HMO proposes to utilize. Reimbursement
					 information submitted to the Department under this paragraph may not be
					 disclosed or produced for inspection or copying to a person other than the
					 Secretary or the Secretary's representatives, without the consent of the plan
					 which provided the information, unless otherwise ordered by a court.
(5) A copy of the HMO's proposed contracts
					 with individual enrollees and groups of enrollees describing the health care
					 coverage to be provided to each individual or group.
(6) A description of the proposed plan
					 services area by county, including demographic data of prospective enrollees
					 and location of contracted providers.
(7) A detailed description of the applicant's
					 proposed enrollee complaint and grievance systems.
(8) A detailed description of the applicant's
					 proposed system for ongoing quality assurance consistent with the requirements
					 of §
											9.674 (relating to quality
					 assurance standards).
(9) A
					 detailed description of the applicant's proposed UR system consistent with the
					 requirements of §§
											9.751-9.753 (relating to UR system
					 description; UR system standards; and time frames for UR).
(10) A copy of the applicant's proposed
					 confidentiality policy.
(11) A
					 detailed description of the applicant's proposed provider credentialing system,
					 and standards for ongoing recredentialing activities incorporating quality
					 assurance, UR and enrollee satisfaction measures.
(12) A description of the applicant's
					 capacity to collect and analyze necessary data related to utilization of health
					 care services and to provide the Department with the periodic reports specified
					 in §
											9.604 (relating to plan reporting
					 requirements), including a description of the system whereby the records
					 pertaining to the operations of the applicant, including membership and
					 utilization data, are identifiable and distinct from other activities the
					 entity undertakes.
(13) If the
					 applicant intends to delegate any UR functions to a subcontractor, evidence of
					 the subcontractor's certification as a CRE under Subchapter K (relating to
					 CREs) if the certification is required.
(14) A detailed description of the
					 applicant's ability to assure both the availability and accessibility of
					 adequate personnel and facilities to serve enrollees in a manner enhancing
					 access, availability and continuity of covered health care services.
(15) A copy of each contract with an
					 individual or entity for the performance on the HMO's behalf of necessary HMO
					 functions, including marketing, enrollment and administration, and each
					 contract with an insurance company, hospital plan corporation or professional
					 health services corporation for the provision of insurance or indemnity or
					 reimbursement against the cost of health care services provided by the
					 HMO.
(16) A job description for the
					 medical director.
(17) A procedure
					 for referral of enrollees to nonparticipating providers.
(18) A copy of the HMO'S proposed general
					 subscriber literature including the member handbook.
(19) A copy of the HMO's most recent
					 financial statement.
(20) Other
					 information the applicant may wish to submit for consideration.
(21) Other information the Department
					 requests as necessary to review the applicant's application for compliance with
					 the HMO Act, Act 68 and this chapter.
This section cited in 28 Pa. Code §
													9.635 (relating to issuance of a
						  certificate of authority to a foreign
						  HMO).