Exhibit B - Application for Registration of a Utilization Review Organization

Current through Register Vol. 46, No. 15, April 8, 2022

1. Name of Applicant ______________________________________________________

Type of Applicant (check one):

Corporation

Partnership

Limited Liability Corporation

Other (Describe) _________________________________________________________

FEIN ___________________

Contact Person __________________________________________________________

Business Telephone Number ( )______________________________________________

Fax Number ( )___________________________________________________________

Email Address __________________________________________________________

2. Type of URO (check all that apply):

Health Care Utilization Review (as defined in Section 4520.30 of this Part) Workers' Compensation Review (as defined in 50 Ill. Adm. Code 2905.10 )

Check all categories that apply (as applicable):

Licensed HMO providing utilization review services outside of the HMO (as defined in 50 Ill. Adm. Code 4521.20)

Licensed HMO providing utilization review services only within that HMO (as defined in 50 Ill. Adm. Code 4521.20)

Third Party Administrator

Licensed Insurance Company providing utilization review services outside of that Insurance Company

Licensed Insurance Company providing utilization review services only within that Insurance Company

Hospital or Medical Group providing utilization review services for other than internal purposes

Workers' Compensation URO

Other (Describe) ___________________________

3. Business Address

Street (do not use PO Box) _______________________________________________

City _____________________ State ____________ Zip ___________ - ____________

4. Mailing Address

Street or P.O. Box ______________________________________________________

City _____________________ State ____________ Zip ___________ - ____________

5. Business Telephone Number ( )____________________________________________

Toll Free Number ( )_____________________________________________________

FAX Number ( )________________________________________________________

Email Address/Website _________________________________________________

6. Agent for Service of Process in Illinois

Name _______________________________________________________________

Street Address (do not use P. O. Box) _______________________________________

City _____________________ State ____________ Zip ___________ - ____________

7. For each Utilization Review Program supply the following information:

a) The name, address, telephone number and normal business hours of the utilization programs.

b) The organization and governing structure of the utilization review programs.

c) The number of reviews in Illinois for which utilization review is conducted by each utilization program for the current year.

Health Reviews

Workers' Compensation Reviews

d) Hours of operation of each utilization review program.

e) Description of the grievance process for each utilization program.

f) Please check (all that apply) to determine if you are using the Health Standards and/or the Workers' Compensation Standards in order to meet or exceed URAC Standards and provide the Department with a copy of your current certificates, if applicable.

Health Utilization Standards

Workers' Compensation Standards

g) Number of reviews in Illinois for which utilization review was conducted for the previous calendar year for each utilization review program.

Health Reviews

Workers' Compensation Reviews

h) Written policies and procedures for protecting confidential information according to applicable State and Federal laws for each utilization review program.

i) Biographical information for organization officers and directors. The biographical affidavits shall include, but not be limited to, the following information: identifying information; affiant's identifying and contact information; affiant's educational, residential and employment history; affiant's professional, business and technical licenses and memberships; a complete history of affiant's fidelity bonding; criminal charges and convictions; civil, regulatory, administrative and disciplinary actions in an individual or corporate capacity; a complete history of affiant's bankruptcy, insolvency, liens and foreclosures in an individual or corporate capacity; affiant's consent to release background reports to the Department and consent for third parties to cooperate in the gathering of background information; and affiant's and his or her immediate family's equity holdings in any entity subject to insurance regulation. The Department will accept the biographical affidavit, and any supplement to that affidavit, that is obtained from the website of the NAIC or the Department. Biographical affidavits shall be stamped "confidential" by the URO.

8. Indicate accreditation status below.

a) Health accredited by:

URAC

NCQA

JCAHO

AAAHC (as defined in 50 Ill. Adm. Code 4520.130(b))

b) Workers' Compensation accredited by:

URAC Health Standards

URAC Workers' Compensation Standards

c) Unaccredited

9. Check Enclosed

a) Accredited fee $1500 biennially

b) Unaccredited fee $3000 biennially

10. Affirmation (to be signed by an officer or director of the URO only):

I, ___________________________________________________ do hereby certify that

(typed name, title)

____________________________________________________________________

(URO)

complies with the Health and/or Workers' Compensation Utilization Management Standards of URAC sufficient to achieve URAC accreditation or submits evidence of accreditation by URAC for its Health and/or Workers' Compensation Utilization Management Standards, and do hereby affirm that all of the information presented in this application is true and correct.

_________________________________________ ___________________________

(signature) (date)

Please mail completed application to:

Illinois Department of Insurance

Utilization Review Unit

320 West Washington Street

Springfield IL 62767-0001

(217) 558-2309

Notes

Recodified from EXHIBIT D at 41 Ill. Reg. 4982. Amended at 42 Ill. Reg. 20417, effective 11/1/2018 Amended at 43 Ill. Reg. 11479, effective 9/24/2019