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
Universal Citation: OK Admin Code 310:657-21-4
Current through Vol. 42, No. 1, September 16, 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.
(2) The application to renew a certificate requests the following:
(A) Any changes in the information provided
in OAC 310:657-21-4; and
(B) Data
on the Plan's experience, including revenues and expenses, changes in financial
position, employee population per month, hospital days and ambulatory
encounters per injured worker, encounters by type of health professional,
disputes and grievances processed, peer review, quality control, medical
records and utilization review systems.
(3) The Commissioner may require such other information as necessary to decide on the application.
Added at 12 Ok Reg 2977, eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 14 Ok Reg 2264, eff 6-12-97; Amended at 23 Ok Reg 2404, eff 6-25-06
Disclaimer: These regulations may not be the most recent version. Oklahoma may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
