APPLICATION FOR CERTIFICATE OF AUTHORITY
§ 9.631. Content of an application for an HMO certificate of authority.
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.
Cross References This section cited in 28 Pa. Code § 9.635 (relating to issuance of a certificate of authority to a foreign HMO).
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