(c) Application Form (WHWCPO-1).
Identification of Organization.
Name of Applicant.
a. Legal name:
b. Please list all fictitious names you
intend to use
A. Type of Filing: Indicate the
type of filing by checking and completing the appropriate items:
1. () Original application for organization
authorization.
2. () Amendment #___
to a pending application dated __________ for organization authorization.
(Complete Item A-5 below.)
3. ()
Notice of a proposed material modification (Complete Item A-5 below.)
4. () Amendment filed by an organization
because of a change in the information contained in the original application.
(Complete Item A-5 below.)
5. Item
numbers being amended
Exhibit numbers being amended
B. Other Agencies.
1. If applicant has made or intends to make
any filing relating to its plan of operation to any other state or federal
agency, check here ___, and attach Exhibit B-1 identifying each such agency,
and the nature, purpose and (projected) date of each such filing.
Additional Exhibits: An original application for
organization authorization must include the completed form specified in this
subsection and the exhibits required.
C. Summary of Information in Application.
1. Summary Description of Organization and
Operation. Provide as Exhibit C-1 a summary description of the organization and
operation of applicant's business as a workers' compensation health care
provider organization, covering the highlights and essential features of the
information provided in response to the other portions of this application
which is essential or desirable to an effective overview of the applicant's
workers' compensation health care business, including a summary of the
applicant's experience in the provision of workers' compensation health
care.
2. Summary Description of
Start-up. Provide as Exhibit C-2 a concise description of applicant's start-up
program and its assumptions, including such program's operating, capitalization
and financial assumptions. Indicate applicant's projected date for the
beginning of operations, and discuss the factors which require such
date.
D. Organization and
Affiliated Persons.
1. Type of Organization.
a. Corporation. If applicant is a
corporation, attach as Exhibits D-1-a-I, D-1-a-ii, D-1-a-iii and D-1-a-iv
respectively, the Articles of Incorporation, Bylaws, the Corporation
Information Form (Form WCHCPO 1-A) and any other organizational documents or
agreements relating to the internal affairs of the applicant.
b. Partnership. If applicant is a
partnership, attach as Exhibits D-1-b-I, D-1-b-ii and D-1-b-iii respectively,
the Partnership Agreement, the Partnership Information Form (Form WCHCPO 1-B)
and any other organizational documents or agreements relating to the internal
affairs of the applicant.
c. Sole
Proprietor. If applicant is a sole proprietorship, attach as Exhibit D-1-c the
Sole Proprietorship Information Form. (Form WCHCPO 1-C)
d. Other Organization. If applicant is any
other type of organization, attach as Exhibit D-1-d Articles of Association,
trust agreement, or any other applicable documents, and any other
organizational documents or agreements relating to the conduct of the internal
affairs of the applicant, and attach as Exhibit D-1-d-ii the Information Form
for other than Corporations, Partnerships, and Sole Proprietorships. (Form
WCHCPO 1-D)
e. Individual
Information Sheet. Attach as Exhibit D-1-e, an Individual Information Sheet
(Form WCHCPO 2) for each natural person named in any exhibit in Item
D-1.
2. Contracts with
Affiliated Persons, Principal Creditors and Providers of Administrative
Services.
a. Persons to Be Identified. Attach
as Exhibit D-2-a, a list identifying each individual or entity who is a party
to a contract with applicant, if such contract is one for the provision of
administrative services to the applicant or any such party is an Affiliated
Person or Principal Creditor (Rule 9771.60(c) and (j)) of the applicant. As to
each such person, show the following information in columnar form:
(i) The names in alphabetical
order.
(ii) The exhibit and page
number of the contract (including loans and other obligations).
(iii) The type of contract or loan.
(iv) Each relationship which such individual
or entity bears to the applicant (officer, director, partner, trustee, member,
Principal Creditor, employee, administrative services provider, health care
services provider, or shareholder).
3. Other Controlling Persons. Does any
individual or entity not named as a contracting party in Item D-2 or any
exhibit thereto have any power, directly or indirectly, to manage, influence,
or administer the operation, or to control the operations or decisions, of
applicant?
If the appropriate response to this item is "yes," attach
as Exhibit D-3 a statement identifying each such person or entity and
explaining fully such person's power or control, and summarizing every contract
or other arrangement or understanding (if any) with each such person. (Each
such contract should be submitted pursuant to Subsection D-2.)
4. Criminal, Civil and Administrative
Proceedings. Within the preceding 10 years, has the applicant, its management
company, or any Affiliate of the applicant (Rule 9771.60(c)), or any
controlling person, officer, director or other person occupying a principal
management or supervisory position in such organization, management company or
Affiliate, or any person intended to hold such a relationship or position, been
convicted of or pleaded nolo contendere to a crime, or been held to have
committed any act involving dishonesty, fraud or deceit in a judicial or
administrative proceeding to which such person was a party?
If "yes," attach a separate exhibit as to each such
person designated Exhibit D-4, identifying such person and fully explaining the
crime or act committed. Also, attach a copy of the exhibit to any Individual
Information Sheet required by Item D-1-e for such individual.
5. Employment of Barred Persons. Has the
organization engaged or does the organization intend to engage, as an officer,
director, employee, associate, or provider, any person named in (i) any order
of the Commissioner pursuant to Section 1386(c) or Section 1388(d) of the
Knox-Keene Health Care Service Plan Act of 1975, (ii) any similar order of the
Insurance Commissioner under the Insurance Code barring or otherwise
prohibiting such person from being employed or otherwise engaged as an officer,
director, employee, associate or provider of any entity subject to the
jurisdiction of the Insurance Commissioner, or (iii) any administrative orders
issued by a professional licensing board or by the Department of Industrial
Relations? If the appropriate response to this item is "yes," attach as Exhibit
D-5 a statement identifying each such person and explaining fully the scope of,
and the circumstances giving rise to, such order.
E. Contracts with Providers.
1. Compliance with Requirements. Attach as
Exhibit E a statement in tabular form for each provider contract, and for each
standard form contract and its variations, if any, specifying the provisions of
such contract which comply with the following provisions of the Act and rules:
| Section | 4600.6(g) | | |
|
|
| 4600.6(I)(8) |
|
|
|
|
| 4600.6(n) |
|
|
|
|
|
| Rules | 9771.69 |
|
|
|
|
| 9771.70 |
|
|
|
|
| 9772
through 9778 |
2. The provisions describing the mechanism by
which payments are to be rendered to the provider clearly identified by the
name of the provider.
F.
Workers' Compensation Health Care Contracts.
Compliance with Requirements. Attach as Exhibit F a
schedule in tabular form for each workers' compensation health care contract
and each standard form workers' compensation contract, identifying the
particular provision of such contract which complies with the sections listed
below, covering also any variations made in standard form contracts. As to any
provision which varies from the applicable provision of the Act or rules,
identify such provision in Exhibit F.
| Section | 4600.5(e)(7)(B) | | |
|
|
| 4600.6(e) |
|
|
|
|
|
| Rules | 9771.67 |
|
|
|
|
| 9771.69 |
|
|
|
|
| 9772 -
9778 |
G. Advertising.
Attach as Exhibit G a copy of any advertising which is
subject to Section 4600.6 of the Code and which applicant proposes to use. With
respect to each proposed advertisement indicate the contract(s) by name and by
exhibit number(s) to which such advertisement relates and identify the employer
segment to which the advertisement is directed.
H. Marketing of Workers' Compensation Health
Care Contracts.
Attach as Exhibit H a statement describing the methods by
which applicant proposes to market workers' compensation health care contracts,
including the use of employees, or contracting solicitors or solicitor firms,
their method or form of compensation, and the methods by which applicant will
obtain compliance with Rules 9771.64, 9771.65, and 9771.83.
I. Supervision of Marketing.
Attach as Exhibit I a statement setting forth applicant's
internal arrangements to supervise the marketing of its workers' compensation
health care contracts, including the name and title of each person who has
primary management responsibility for the employment and qualification of
solicitors, advertising, contracts with solicitors and solicitor firms and for
monitoring and supervising compliance with contractual and regulatory
provisions.
J. Solicitation
Contracts.
1. Attach as Exhibit J-1 a list of
all persons (other than any employee of the organization whose only
compensation is by salary) soliciting or agreeing to solicit the sale of
workers' compensation health care contracts on behalf of the applicant. For
each such person, identify by exhibit number that person's contract furnished
pursuant to Item K-2 and, if such contract does not show the rate of
compensation to be paid, specify the person's rate of compensation.
2. Attach as Exhibit J-2, a copy of each
contract or proposed contract between applicant and the persons named in
Exhibit J-1 for soliciting the sale of or selling workers' compensation health
care contracts on behalf of applicant. If a standard form contract is used,
furnish a specimen of the form, identify the provision and terms of the form
which may be varied and include a copy of each variation.
K. Workers' Compensation Health Care Contract
Enrollment Projections.
NOTE: All projections are to cover the period commencing
from the applicant's commencement of operations as an authorized and certified
workers' compensation health care provider organization for two years.
1. Projections. Attach as Exhibit K-1
projections of applicant's enrollments under workers' compensation health care
provider contracts with self-insured employers, groups of self-insured
employers, or insurers of employers (individually, "Employer"; collectively,
"Employers") for the periods specified in the above note. Exhibit K-1 is to
contain the following information with respect to each anticipated workers'
compensation health care contract:
a. The name
of the Employer.
b. The number of
potential employees eligible to receive workers' compensation health care from
the organization who are employed by the Employer.
c. The locations within and around
applicant's service area in which the potential employees live and
work.
d. The estimated date (or
period after authorization by the Administrative Director and certification by
the Workers' Compensation Division of the Department of Industrial Relations)
for entry into the workers' compensation health care contract.
e. Identification of the workers'
compensation health care contract anticipated with the Employer, by reference
to Exhibit F. If more than one type of workers' compensation health care
contract is expected with an Employer, each contract must be covered
separately.
f. The projected number
of employees on a monthly basis for the initial period specified in the Note,
above, and quarterly for the following year.
2. Substantiation of Projections. Attach as
Exhibit K-2 for each workers' compensation health care contract specified in
Exhibit K-1 a description of the facts and assumptions used in connection with
the information specified in that exhibit and include documentation of the
source and validity of such facts and assumptions.
3. Letters of Interest. Attach as Exhibit K-3
letters of interest or intent from each Employer listed in Exhibit K-1, on the
letterhead of the Employer and signed by its
representative.
L.
(Reserved for future use.)
M.
Current Viability.
1. Financial Statements.
a. Attach as Exhibit M-1-a the most recent
audited financial statements of applicant, accompanied by a report,
certificate, or opinion of an independent certified public accountant, together
with all footnotes to such financial statements.
b. If the financial statements attached as
Exhibit M-1-a are for a period ended more than 60 days before the date of
filing of this application, also attach as Exhibit M-1-b financial statements
prepared as of date no later than 60 days prior to the filing of this
application consisting of at least a balance sheet, a statement of income and
expenses, and any accompanying footnotes; these more recent financial
statements need not be audited, so long as they are prepared in accordance with
generally accepted accounting principles.
2. Provision for Extraordinary Losses. The
following requirements require an initial applicant to submit legible copies of
the actual policies of insurance (including any riders or endorsements) or
specimen copies of the policies of insurance which show all of the terms and
conditions of coverage, or with respect to those items expressly allowing for
self-insurance, allow applicant to provide evidence of self-insurance at least
as adequate as insurance coverage.
a. Attach
as Exhibit M-2-a evidence of adequate insurance coverage or self- insurance to
respond to claims for damages arising out of furnishing workers' compensation
health care (malpractice insurance).
b. Attach as Exhibit M-2-b evidence of
adequate insurance coverage or self-insurance (e.g., appropriate reserve set
aside to fund likely liabilities associated with uninsured costs) to respond to
claims for tort claims, other than with respect to claims for damages arising
out of furnishing health care services.
c. Attach as Exhibit M-2-c evidence of
adequate insurance coverage or self-insurance to protect applicant against
losses of facilities upon which it has the risk of loss due to fire or other
causes. Identify facilities covered by individual policies and indicate the
basis upon which applicant believes that the insurance thereon is
adequate.
d. Attach as Exhibit
M-2-d, evidence of fidelity bond coverage for at least the amounts specified in
Rule 9771.74, in the form of a primary commercial blanket bond or a blanket
position bond written by an insurer licensed by the California Insurance
Commissioner, providing 30 days' notice to the Administrative Director prior to
cancellation, and covering each officer, director, trustee, partner and
employee of the organization, whether or not compensated.
e. Attach as Exhibit M-2-e evidence of
adequate workers' compensation insurance coverage against claims which may
arise against applicant.
N. Fiscal Arrangements.
1. Maintenance of Financial Viability. Attach
as Exhibit N-1 a statement describing applicant's arrangements to comply with
Section 4600.6(m) of the Code and Rule 9771/73.
2. Provider Claims. Attach as Exhibit N-2 a
statement describing applicant's system for processing claims from providers
for payment, including the rules defining applicant's obligation to reimburse,
the standards and procedures for applicant's claims processing system
(including receipt, identification, handling, screening, and payment of
claims), the timetable for processing claims, and procedures for monitoring the
claims processing system.
3. Other
Business. If the applicant is or will engage in any business other than as a
workers' compensation health care provider organization, attach as Exhibit N-3
a statement describing such other business, its relationship to applicant's
business as an organization, and the anticipated financial risks and
liabilities of such other business. If the financial statements and projections
in Exhibits M-1-a, do not include such other business,
explain.
