American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF LABOR WORKERS' COMPENSATION DIVISION APPLICATION FOR CERTIFICATION BILL SCREENING AND UTILIZATION REVIEW QUALIFICATIONS FOR UTILIZATION REVIEW ENTITY Purpose and Scope of Application To require certain persons or entities to obtain either a Limited or Full certification from the Department of Labor, Workers' Compensation Division for Bill Screening and Utilization Review of Compensable Medical Coverage under the Workers' Compensation Act. The purpose of this application is to screen applicants to ensure that utilization review entities adhere to the provisions of the Act for reasonable standards for conducting utilization review, foster greater coordination and cooperation between health care providers and that utilization review agents are acting in the capacity for which they are certified. There is no requirement that outside utilization review entity vendors be hired to perform utilization review activities in accordance with these rules. Entities qualified by the Department, either in a Limited or Full Certification, may perform the functions as certified by the Department of Labor, Workers' Compensation Division. It is required that for the Certifications, either Full or Limited, the Entity applying for Certification understand and have thorough knowledge of the requirements of the Law as it pertains to the application for Certification. Scoring of the Application shall determine the Certification to be issued. Limited Certification will be issued for a score of 10, or to those entities applying for certification as described in rule 480-5-5-.05 and 480-5-5-.06(1). Full Certification will be issued for a score of 15, or to those entities applying for certification as described in rule 480-5-5-.05 and 480-5-5-.06. Revocation of Certification and the appeals process is as described in rule 480-5-5-.06 and 480-5-5-.23. The Department of Labor maintains the right to inspect or verify that the information in the Application for Certification is correct and truthful. The Entity shall produce necessary documentation to the Department of Labor that would verify compliance and qualifications under any of the requirements of the Act. The Department of Labor shall be specific as to what documentation is being requested. Certification shall be issued for a period of two years. DEPARTMENT OF LABOR WORKERS' COMPENSATION DIVISION APPLICATION FOR CERTIFICATION BILL SCREENING AND UTILIZATION REVIEW QUALIFICATIONS FOR UTILIZATION REVIEW ENTITY AS DEFINED IN RULES 480-5-5-.05, 480-5-5-.06 AND 480-5-5-.07 1. GENERAL INFORMATION Name of Agency Address () Telephone Number () Toll Free Number Contact Person Title Email Address ******** 2. CERTIFICATION ALREADY HELD: Certified by Alabama Department of Public Health (Act 94-786), Health Care Services Utilization Review Act No(0) Yes(15) Current AAHC/URAC Certification No(0) Yes(15) If answer is YES, further completion of application is unnecessary, If certified under the Act 94-786 or holding URAC Accreditation, attach a copy of certification and mail to the Department of Labor. See page four, sign, and return this application to the Department of Labor, Division of Workers' Compensation. TOTAL WC5 American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com Application as Utilization Review Entity Page Two 3. PURPOSE FOR APPLICATION: (I) Application for LIMITED CERTIFICATION AS A UTILIZATION REVIEW ENTITY FOR PERFORMANCE OF APPROVALS ONLY. a. Approval of medical charges through bill screening methodology using the Maximum Fee Schedule and the application of the appropriate adjudication rules, using criteria as set in 480-5-5-.05 for approvals only. No(0) Yes(5) b. Approval/Certification of testing, inpatient stays, outpatient care and any other requests for authorization of treatment using criteria as set in 480-5-5-.01 through 480-5-5-.37. No(0) Yes(5) If answer is yes on either a or b of number 3, (I) complete the following: i. Name of utilization review agency performing 1st thru 3rd level clinical review, if applicable. ii. Address iii. () Telephone Number iv. () Toll Free Number Not applicable (0) Information Completed (10) If applying Entity is requesting qualification only to approve certifications and medical services, no further completion of application is necessary. If Entity will be using other Utilization Review Entities for 1st through 3rd Level Clinical Review as noted in 480-5-5-06, the Entity must have filed and received certification from the Department of Labor, Workers' Compensation Division to perform Utilization Review. You must have a copy of their Certification and you must notify that entity that they are the designated Utilization Review Entity under the Act. TOTAL WC 50 American LegalNet, Inc. www.FormsWorkFlow.com Application as Utilization Review Entity Page Three 3. PURPOSE FOR APPLICATION continued (II) Application for FULL CERTIFICATION AS AN UTILIZATION REVIEW ENTITY (Full certification is necessary for denials of medical necessity) a. Be qualified per rule 480-5-5-.06 (2), (6), (7) for First Level Clinical Reviewer No(0) Yes(5) b. Be qualified per rule 480-5-5-.06 (3), (6), (7) for Second Level Clinical Reviewer. No(0) Yes(5) c. Be qualified per rule 480-5-5-.06 (4), (6), (7) for Third Level Clinical Reviewer. No(0) Yes(5) TOTAL If the applying Entity contracts for utilization review services at any Clinical level review, the applicant Entity will be responsible for ensuring that the contractor has a valid certificate in effect for workers' compensation issued by the Department of Labor. The applicant Entity must have a copy of the contractor's Certification as a Certified Entity and the applicant Entity shall notify that contractor that they are the designated Utilization Review Entity under the Act. After completion of the above, read and sign page 4, and return completed application to the Department of Labor, Workers' Compensation Division. An individual serving as a Clinical Reviewer for a URE does not have to be individually certified by the Department of Labor as a URE. WC 50 American LegalNet, Inc. www.FormsWorkFlow.com Application as Utilization Review Entity Page Four STATEMENT OF CERTIFICATION I (we) do hereby certify on behalf of that I (we) have reviewed and do solemnly swear or affirm that I (we) am (are) familiar with the Laws of Alabama relating to Workers' Compensation, that I have complied with all of the requirements of the Alabama Workers' Compensation Act and the Department's Administrative Code for Bill Screening and Utilization Management with written procedures and policies describing the appeals process. All the foregoing information is true and complete and correct to the best of my knowledge and belief. Company Signature of Affiant Name (typewritten) Title (typewritten) Sworn to and Subscribed Before Me This day of 20 Notary Public Mail to: Department of Labor Workers' Compensation Division 649 Monroe Street Montgomery, Alabama 36131 WC 50