(1) The name,
address and telephone number of the applicant as it should appear on the
Department's official list of certified CREs.
(2) Information relating to its organization,
structure and function, including the following:
(i) The location of the principal office
handling UR.
(ii) The articles of
incorporation and bylaws, or similar documents regulating the internal affairs
of the applicant.
(iii) The name of
each owner of more than 5% of the shares of the corporation, if the applicant
is a public corporation.
(iv) A
chart showing the internal organization of the applicant's management and
administrative staff.
(3)
The names and resumes of each officer, director and senior
management.
(4) A listing of each
plan in this Commonwealth for which the applicant currently conducts
UR.
(5) A description of the
applicant's:
(i) Ability to respond to each
telephone call received as required by section 2152 of the act (40 P. S. §
991.2152), including toll-free telephone
numbers and the applicant's system to provide access during nonbusiness
hours.
(ii) Acceptable selection
and credentialing procedures and criteria for physician and psychologist
clinical peer reviewers.
(iii)
Ability to arrange for a wide range of health care providers to conduct
reviews. The applicant shall have access to a pool of clinical peer reviewers
sufficient to reasonably assure that appropriately qualified reviewers will be
available on a timely basis.
(iv)
Procedures for protecting the confidentiality of medical records and
certification that the applicant will comply with the confidentiality
provisions in section 2131 of the act (40 P. S. §
991.2131) and other applicable State and
Federal laws and regulations imposing confidentiality requirements.
(v) Procedures to ensure that a health care
provider is able to verify that an individual requesting information on behalf
of the plan is a representative of the plan.
(vi) Capacity to maintain a written record of
UR decisions adverse to enrollees for at least 3 years, including a detailed
justification and all required notifications to the health care provider and
enrollee.
(vii) Evidence of
approval, certification or accreditation received by a Nationally recognized
accrediting body in the area of UR, if it has secured the approval,
certification or accreditation.
(viii) The length of time the applicant has
been operating in this Commonwealth, if applicable.
(ix) A list of three clients, if any, for
which the applicant has conducted UR including the name, address, position and
telephone number of a contact person for each client. The Department may
contact these references for an assessment of the applicant's past performance
and its ability to meet the time frames for prospective, concurrent and
retrospective UR in section 2152 of the act (40 P. S. §
991.2152).
