N.J. Admin. Code Tit. 11, ch. 24B, APPENDIX, exh. 2
| New Jersey Department of Banking and Insurance Application | |
| Checklist for ODS Certification or Recommendation for License |
Please use this checklist to complete the application package. Refer to N.J.A.C. 11:24B-2.2, 2.3, and 2.4 for more detailed instructions (applicants for license should refer also to N.J.A.C. 11:22-4). Applications should be mailed to: ODS Certification, New Jersey Department of Banking and Insurance, Market Regulation, P.O. Box 329, Trenton, NJ 08625-0329; street address: 20 West State Street, 9th Floor, Trenton, NJ 08625.
| Part A | |
| (N.J.A.C. 11:24B-2.3) |
...1. A
completed Application Cover Sheet
...2. A completed Irrevocable Consent to
Jurisdiction of the Commissioners and New Jersey Courts
...3. A completed Appointment of Attorney for
the State of New Jersey
...4. A
completed Financial Risk Affidavit (applicants for certification
only)
...5. A copy of the ODS's
basic organizational documents, as defined at
N.J.A.C.
11:24B-1.2
...6. A copy of the ODS's executed by-laws,
plan of operation, rules and regulations, or similar documents intended to
regulate the conduct of the ODS's internal affairs
...7. A Biographical Affidavit completed for
each of the individuals who are, or are intended to be, responsible for the
conduct of the affairs of the ODS, including:
i) members of the ODS's board of directors,
executive committee or other governing board or committee;
ii) the ODS's principal officers, and medical
director, if applicable;
iii) any
person who owns or has the right to acquire 10 percent or more of the voting
securities of the ODS;
iv) each
person that has loaned funds to the ODS for the operation of the ODS's
business; and
v) partners or
members, in the case of a partnership or association
...8. A business plan consisting of:
(i) an organizational chart of the
ODS
(ii) a narrative description of
the ODS, its facilities, and personnel, and the health care services to be
offered by the ODS to a carrier;
(iii) a list of the geographical areas in
which the described health care services are to be performed and approximate
number of each type of provider who will provide the health care
services;
(iv) a description of any
administrative services for which the ODS shall be responsible on behalf of the
carrier;
(v) a list of any
affiliate of the ODS that provides services to the ODS in New Jersey and a
description of any material transaction between the affiliate and the
ODS;
(vi) a description of any
arrangements between the ODS and any other ODS or subcontractor for services
associated with the provisions of health care services;
(vii) a description of any reinsurance or
stop loss arrangements;
(viii) a
plan, in the event of insolvency of the ODS, for continuation of the health
care services to be provided in accordance with existing contracts and
laws;
(ix) a description of the
means by which the ODS will be compensated under contracts with
carriers;
(x) a description of the
arrangement for the ODS reporting of data to the carriers and a description of
the carrier's oversight responsibility.
...9. A specimen copy of all provider
agreements made or intended to be executed between the ODS and
providers
...10. A specimen copy of
all contracts made or intended to be executed between the ODS and any other ODS
or subcontractor for services associated with the provision of health care
services
...11. A specimen copy of
all management agreements made or to be executed between the ODS and one or
more carriers
...12. A list of all
administrative, civil or criminal actions and proceedings to which the ODS, its
affiliates, or persons who are responsible for the conduct of the affairs of
the ODS or affiliate, have been subject, including a statement regarding the
resolution of such actions and proceedings.
...13. A list of the carriers with which the
ODS has contracted or intends to execute a contract pending the approval of the
application
...14. A list of all
states in which the ODS has been or currently is doing business as described in
the application
...15. The
appropriate fee set forth at
N.J.A.C.
11:24B-2.9
| Part B | |
| (N.J.A.C. 11:24B-2.4) |
...1. Services
for which certification is being sought (please circle all that apply):
(1) Performance of one or more types of
health care services delivery
(2)
Network management
(3)
Credentialing and recredentialing
(4) Utilization management
development
(5) Utilization
management application
(6)
Utilization management appeals
(7)
Member complaints
(8) Provider
complaints
(9) Continuous quality
improvement
...2. For
performance of one or more types of health care services delivery:
...(a) List of names of all providers by
county, municipality, zip code, and services
...(b) Map of the service area identifying
the location of the participating providers
...(c) Criteria to assure the availability
and accessibility of services to be performed
...3. For network management:
...(a) Demonstration of adequacy of the
network for services offered in relation to population to be served consistent
with standards of
N.J.A.C.
11:24B-3.5
...(b) Demonstration of the CQI
program
...(c) Demonstration of the
complaint and appeal system for providers
...(d) Demonstration of the provider
participation panel
...(e)
Demonstration of the hearing panel for provider terminations
...(f) Demonstration of records maintenance
procedures and standards
...(g)
Credentialing and recredentialing standards
...(h) Statement of deficiencies and POCs
with respect to licensed facilities
...4. For credentialing and recredentialing:
...(a) Policies and procedures, demonstrating
compliance with
N.J.A.C.
11:24B-3.6
...(b) Designated medical director and
his/her functions
...(c)
Explanation of linkage and coordination with the CQI and complaint systems of
the carrier(s) and/or their other contractor(s), including flow
chart(s)
...5. For
utilization management development:
...(a)
Policies and procedures for developing protocols and guidelines, demonstrating
compliance with
N.J.A.C.
11:24B-3.7
...(b) Designated medical director and
his/her functions
...(c) Copy of
the protocols and guidelines developed, and instructions for use
...6. For performance of
utilization management:
...(a) Policies and
procedures, demonstrating compliance with
N.J.A.C.
11:24B-3.8
...(b) Designated medical director and
his/her functions
...(c)
Explanation of medical director's oversight, if employed by the
carrier
...(d) Explanation of the
UM criteria used
...7.
For utilization management appeals:
...(a)
Policies and procedures, demonstrating compliance with
N.J.A.C.
11:24B-3.9
...(b) Designated medical director and
his/her functions
...(c) Flow chart
demonstrating communication and decision-making, if the medical director is
employed by the carrier
...(d)
Specimens of letters regarding appeal rights and decisions on appeals to be
sent to both covered persons and providers.
...8. For member complaints:
...(a) Policies and procedures, demonstrating
compliance with
N.J.A.C.
11:24B-3.1 2
...(b) Explanation of linkage and
coordination with the CQI and complaint system of the carrier(s) and/or their
other contractor(s)
...(c)
Explanation of how complaints are segregated among carriers (and other
clients)
...(d) Specimens of the
letters regarding complaint and complaint resolution to be sent to covered
persons and providers acting on behalf of covered persons
...9. For provider complaints:
...(a) Policies and procedures, demonstrating
compliance with
N.J.A.C.
11:24B-3.1 1
...(b) Explanation of linkage and
coordination with the CQI and complaint system of the carrier(s) and/or their
other contractor(s)
...(c)
Explanation of how complaints are segregated among carriers (and other
clients)
...(d) Specimens of the
letters regarding a complaint and complaint resolution to be sent to
providers.
...10. For
continuous quality improvement:
...(a)
Policies and procedures, demonstrating compliance with
N.J.A.C.
11:24B-3.10
...(b) Explanation of linkage and
coordination with the complaint systems and other continuous quality
improvement components that the carrier(s) may have
...(c) Designated medical director and
his/her functions
| Part C | |
| (N.J.A.C. 11:24B-2.2) |
...1.
Application in 3-ring binder(s), labeled with the ODS' name, and serially
numbered, if necessary
...2.
Application tabbed, exhibits segregated, and shown in order requested in
regulations
...3. All pages
numbered
...4. All specimen
contracts contain unique identifier in lower left corner of each page
...5. Payment by check or money order made
payable to the Treasurer, State of New Jersey
...6. No items left
blank
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.