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Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 4. Certification Standards for Health Care Organizations

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§9771. Applications for Certification.

(a) Any of the following entities may apply for certification as a health care organization:

(1) A disability insurer licensed by the Department of Insurance to transact health insurance or disability income insurance pursuant to Part 2 of Division 2 of the Insurance Code.

(2) Any workers compensation health care provider organization.

(b) An applicant must meet all of the requirements set forth in this article in order to be certified as a health care organization by the administrative director. Applicants must initially submit to the administrative director, as part of the application, a plan which will provide a clear and concise description of how occupational medical and health care services are to be provided and how each of the requirements in this article are met, and, where specified, in the manner required under each section. HCOs must include all documentation necessary to demonstrate that they meet the requirements for certification.

(c) Health care service plans must provide written certification that at the time of application the applicant is not in violation of any provision of law or rules or orders of the Director of the Department of Managed Health Care, and that there are no outstanding orders, undertakings, or deficiency letters which involve the applicant. Disability insurers must provide written certification that at the time of application they are in good standing with the Department of Insurance. The requirement of this subdivision may be satisfied by verified statement under penalty of perjury by the president or managing officer of an applicant that the applicant meets the requirements of this subdivision, subject to verification by the administrative director.

(d) An applicant who is in compliance with requirements for certification by the Department of Insurance may submit copies of any relevant exhibits, sections or other documents submitted as part of the primary certification application to meet any of the requirements of this article, provided that the applicant (1) verifies that the Department of Insurance has fully reviewed and approved the submitted information, (2) provides a concise narrative identifying any manner in which HCO services will be provided differently from those provided under the primary certification, and (3) provides a concise description for each requirement of this article, specifying how occupational medical and health care services or other services specifically and exclusively required by this article will be met.

(e) Applications must be in writing in the form and manner prescribed by the administrative director, and must be submitted on or after January 1, 1994. The original plus one copy of the application shall be submitted together with a fee as specified in subdivision (c). Each application shall provide, in addition to the plan specified in subdivision (b), the following information:

(1) The names of all directors and officers of the health care organization;

(2) The title and name of the person designated to be the day-to-day administrator of the health care organization.

(3) The title and name of the person designated to be the administrator of the financial affairs of the health care organization.

(4) The name, medical specialty, if any, board certification, if any, and any unrestricted licenses (including states where licensed), of the medical director.

(5) The name, address, and telephone number of a person designated to serve as a liaison for the Division, who is responsible for receiving compliance and informational communications from the Division and for disseminating the same within the HCO organization.

(6) A sample of each type of contract with participating providers, claims administrators, and insurers, and any entities specifically providing services required by this article; and a list of contractors for each type of contract. Copies of contracts shall be made available to the administrative director upon request. The Division will maintain as confidential information pertaining to provider rates and other financial information in accordance with Government Code Section 6254(d)(1).

(7) An organizational chart demonstrating the structural relationships between the medical director, fiscal or financial administrator, and executive officers and administrators.

(8) The identity of any worker's compensation insurer that controls or is controlled by the applicant, as defined by Section 1215 of the Insurance Code.

(f) Each application for certification must be accompanied by a non refundable fee of $2,500.

(g) In lieu of an application for certification, an entity licensed as a full service health care service plan under Section 1353 of the Health and Safety Code (a Knox-Keene Health Care Service Plan Act) and deemed to be an HCO pursuant to Labor Code Section 4600.5(c) shall submit to the administrative director:

(1) a concise description of how the health plan will satisfy the requirements of Labor Code Section 4600.5(c)(1 - 5) and Sections 9772 through 9778, inclusive, of these regulations. At the time the materials required by this subsection are submitted to the administrative director for review, the health plan shall pay a nonrefundable documentation processing and review fee of $1,000; and,

(2) written certification that the health plan is not in violation of any provisions of law or rules or orders of the Director of the Department of Managed Health Care, and that there are no outstanding orders, undertakings, or deficiency letters which involve the health plan. The requirements of this subdivision may be satisfied by verified statement under penalty of perjury by the president or managing officer of the health plan that the plan meets the requirements of this subdivision, subject to verification by the administrative director.


Note: Authority cited: Sections 133, 4600.5, 4600.7, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600 and 4600.5, Labor Code.

 HISTORY 
   
1. New section filed 12-31-93; operative 1-1-94.  Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 93, No. 53).

2. Amendment of subsection (d), new subsection (e)(8) and amendment of subsection (f) filed 2-14-96; operative 2-14-96. Submitted to OAL for printing
only pursuant to Government Code section 11351 (Register 96, No. 7).

3. Repealer of subsection (a)(1), subsection renumbering, amendment of newly designated subsection (a)(2) and subsections (c), (d) and (f), new subsections  (g)-(g)(2) and amendment of Note filed 1-9-2003; operative 1-9-2003 pursuant to Government Code section 11343.4 (Register 2003, No. 2).

4. Amendment of subsections (f) and (g)(1) filed 11-4-2009; operative 1-1-2010  (Register 2009, No. 45).

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