APPLICATION FOR CERTIFICATION OF A CARRIER'S PROFESSIONAL HEALTH CARE REVIEW PROGRAM Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency Health Care Services Division PO Box 30016, Lansing, Michigan 48909 Date of Application Initial Renewal Note: A new application must be submitted whenever there is a change in carrier, service company, or review company. This form is required in accordance with Part 12, R 418.101206 of the Workers' Compensation Health Care Services Rules to receive certification of a carrier's professional review program. I. CARRIER Carrier NAIC No., Self-Insured No., or FEIN Name Address (Street) City, State, Zip Code Telephone No. (Include area code) Contact Person and Email Address Service Company Agency Assigned Number Name Address (Street) City, State, Zip Code Telephone No. (Include area code) Contact Person and Email Address Review Company Employer Identification Name Address (Street) City, State, Zip Code Telephone No. (Include area code) Contact Person and Email Address II. METHODOLOGY/REVIEW STAFF AND CREDENTIALS Attach methodology, according to the workers' comp agency procedure, used to perform a carrier's professional review. R 418.101204(5)(a)-(c) requires that medical appropriateness of services shall be determined through one of the following approaches: 1) Review by licensed, registered, or certified health care professionals. 2) The application by others of criteria developed by licensed, registered, or certified health care professionals. 3) A combination of (1) and (2) according to the type of covered injury or illness. The methodology should include a list of all licensed, registered, or certified health care professionals reviewing case records and medical bills for the above carrier. Provide current licensure information (license #, state of issue, date of expiration and restrictions) and qualifications for medical bill review. In addition, include a list of all peer reviewers with current license information and specialty. *When a service company submits applications for numerous self-insured employers, and the methodology is identical, it is not necessary to submit the professional review methodology more than once. The Workers' Compensation Agency will maintain on file, the review methodology for each service company. **Methodology for professional certification must be submitted once every three years or whenever changes occur. III. AUTHORIZED SIGNATURE By signing this form, I certify that the information included on this form is correct and complete to the best of my knowledge and that the professional review methodology is attached or has already been submitted by the service company and/or their designated agent. I understand that submitting false information is cause for denial of the application or will subject me to penalties as provided by law. Authorized Signature (In Ink) Authorized Name and Email Address (Typed) Date Alternate Person Name Alternate Email Address Alternate Telephone Number LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-590 (Rev. 12/13) Authority: Completion: Penalty: R418.101206 (Part 12) Required None American LegalNet, Inc. www.FormsWorkFlow.com