1 UTILIZATION REVIEW APPLICATION 452CMR 6.00 Revised July 2019 INSTRUCTIONS Applicants must be familiar with 452 CMR 6.00 and Office of Health Policy (223OHP224) procedures and policies in order to complete this document. Information is available on the Department of Industrial Accidents (223DIA224) website www.mass.gov/dia In 223Search224, type in 223Office of Health Policy. All pages in the application, including attachments and exhibits, must be numbered sequentially. Send the application in hardcopy, without staples or divider tabs, along with the application fee to: Department of Industrial Accidents Office of Health Policy Lafayette City Center 2 Avenue de Lafayette Boston, MA 02111 GENERAL INFORMATION The application will be reviewed by the OHP and the applicant notified of approval or non-approval of the application within thirty (30) days from date of receipt. If the Department is unable to approve the application, the applicant may be asked to submit additional information and/or to meet with Departmental staff. The applicant will be notified of approval or non-approval within thirty (30) days from receipt of the revised application. Applicants who are approved by the Department shall receive an agent identification number and a two year Certificate of Approval. Any material change to the Utilization Review Program shall be submitted for review and approval by the Department within thirty (30) days of the change. The written change must be paginated and will be inserted and incorporated into the existing application if approved. Initial review determinations must be conducted at the site of the approved Utilization Review Agent. All documents and information provided by the applicant are subject to disclosure under the provisions of the Public Records Statute, M.G.L. c.66. I. APPLICANT INFORMATION Identify the entity seeking approval to conduct utilization review and the name and address of the utilization review company as it should appear on the Certificate of Approval. If the Utilization Review Agent is a subsidiary of a parent company, provide documentation of the legal entity. The information in sections B, C, and D2 will be posted on the Department website. A. Name of Applicant: B. Name of the Program or D/B/A: C. Address of Site Where UR is Conducted: D. Applicant222s Contact: 1. Corporate Contact a) Name: b) Title: c) Address: d) Telephone: Fax: e) Email: The Commonw ea lth of Massachusetts Department of Industrial Accidents Lafayette City Center 2 Avenue de Lafayette Boston, MA 02111 Telephone: (617) 727-4900 American LegalNet, Inc. www.FormsWorkFlow.com 2 2. Massachusetts Contact [Cannot be the same as Corporate Contact]: a) Name: b) Title: c) Address: d) Telephone: Fax: e) Email: 3. Medical Director: Active Clinical Practice: Yes No If 223No,224 include a separate letter requesting a waiver of the active clinical practice requirement and include the Medical Director222s CV in the application. E. Toll free telephone and fax numbers provided to injured employees and medical providers: Toll-Free Telephone: Fax: Email (If Applicable): Application Submitted By: Date: Typed Name and Credentials II. TREATMENT GUIDELINES: The applicant must acknowledge that MA Treatment Guidelines will be used if applicable to the diagnosis. Identify all secondary treatment guidelines, including other state guidelines, to be used for medical conditions not covered by MA Treatment Guidelines. Please note OHP Informational Bulletin 104 for approved secondary sources. If there is no MA Treatment Guideline and no identified secondary treatment guideline which applies to the medical diagnosis, the Utilization Review Agent should develop an Internal Treatment Guideline in order to conduct the review. The application should set forth the procedure for developing an Internal Treatment Guideline which includes a description as to how the applicant222s internally derived treatment guidelines are developed, reviewed, and revised. The applicant must acknowledge that the medical director will be involved with the development of the internal guideline as well as involvement from several other medical practitioners, with at least one who is of the same school as the requesting provider. Medical professionals involved in the development of an internal guideline must possess current knowledge of the condition under review Internally derived treatment guidelines shall be developed through the use of evidence-based literature, and sources used to develop the guideline should be available for review upon request. Internally derived treatment guidelines shall be maintained in a format similar to the format of the MA Treatment Guidelines and shall be reviewed no less than annually and revised as necessary. III. MEDICAL REVIEWERS and ADMINISTRATIVE STAFF Credentialing Process Provide a detailed description in narrative form of the applicant's process for verification of licensure and credentials of the medical director, school to school reviewers, nurses, and all other medical professionals involved with utilization review. Set forth the procedures to ensure that all clinical reviewers remain licensed and qualified to render utilization review determinations and conduct quality assurance audits. The procedure should specify how often license verification occurs. If any part of the applicant's credentialing/re-credentialing procedure is subcontracted, the applicant should provide a description of the applicant's procedure for monitoring of the sub-contractor's credentialing procedure. The information should include the procedure for license verification, how often the verification occurs, and the party responsible for oversight of the subcontractor. American LegalNet, Inc. www.FormsWorkFlow.com 3 Job Description and Required Qualifications Provide job descriptions for all persons involved in the utilization review process including the medical director, first level reviewers, school to school reviewers, quality assurance committee members, and non-medical administrative assistants. Provide an outline of the formal training for the administrative staff and medical reviewers involved with Massachusetts utilization reviews. Specify required qualifications for each person involved in the utilization review process including: educational background/degree, prior work experience, and prior years of active clinical practice for the medical director, initial reviewers, and school to school reviewers. State whether or not board certification is required for the medical director and school to school reviewers. An Affidavit of Active Practice must be signed by the medical director and each school to school reviewer attesting to active clinical practice of at least 8 hours per week. The medical director222s Affidavit of Active Practice (or waiver) should be included in the utilization review application. The individual reviewer attestation of active practice forms should be included in the application unless the application contains a signed attestation by the medical director confirming that all school to school reviewers signed the attestation of active practice form. If the medical director is not in active clinical practice, the applicant may file a request for a waiver of this requirement and such request should include the medical practitioner222s experience and qualifications. Original signed attestations for all reviewers shall be on file at the approved utilization review site and made available for review upon request. Identification of Medical Director and Reviewers Identify the medical director and each licensed reviewer (including nurses); professional license number; state of licensure; license expiration date; and specialty if applicable. Identification of Utilization Review Program Employees Provide a company organizational flow chart which provides the names, titles, and credentials of employees involved in the utilization review process, and supervisory relationships. IV. UTILIZATION REVIEW PROCESS-APPEAL PROCESS-DETERMINATION LETTERS Provide a detailed narrative of the applicant's procedures for conducting prospective, concurrent, and retrospective reviews