Application for Certification of Qualified Health Plan (QHP) Instructions Please specify if you are requesting certification or re-certification and submit all of the information requested in this application in the order specified. Where attachments are necessary, clearly indicate the application requirement being addressed (i.e. a document labeled "Item D2" would refer to the list of providers that the employer has arrangements for the provision of health-care services). Please submit your application and attachments via mail or email to: Ohio Bureau of Workers' Compensation nd Self-Insurance, 22 Floor 30 West Spring St. Columbus, Ohio 43215-2256 Email: SIINQ@bwc.state.oh.us Certification (check one) QHPs that successfully complete the application process will be certified. To become certified, QHP must: Ensure their panel providers have obtained BWC certification; For those QHP applicants submitting providers who need certified, the potential QHP shall submit individual provider applications for each provider requiring certification. Re-certification QHP Identification 1. Identify the employer and name of the QHP Employer name Employer policy number QHP name Federal tax ID number Contact name Title Street address P.O. box/suite number City State ZIP code Phone number Fax number E-mail address 2. Identify the structure of the QHP (check one) Self-administered: The self-insuring employer has all the resources and tools, and will administer the QHP in house. Vendor administered: The self-insuring employer will contract with a medical-management vendor to provide all of the services necessary for its QHP. A vendor may be any party providing any part of the employer's medical management, including a BWC-certified managed care organization. A third party administrator (TPA) may not provide medical management services for the QHP. Partial vendor administration: The self-insuring employer has some of the resources and tools necessary, and will administer some of the QHP in-house. The self-insuring employer will contract with a medical-management vendor to provide the remainder of the services necessary for its QHP. A TPA may not provide medical management services for the QHP. Other: (Please define) BWC-7251 SI-51 American LegalNet, Inc. www.FormsWorkFlow.com Organization 1. Attach a description of the QHP's structure. Please submit a description of the role of each vendor that will be a component of the QHP, including, but not limited to, TPAs and other medical management vendors. Please submit a table of organization of your QHP, placing all vendors (if applicable) on the chart who are performing functions of your QHP. Describe your plan of oversight for all outsourced functions. 2. Identify the individual who will serve as the day-to-day administrator of the QHP. Name Title Street address P.O. box/suite number City State ZIP code Phone number Fax number E-mail address 3. Identify the individual who will serve as Medical Director or Physician Consultant of the QHP (attach a copy of the physician's license and curriculum vitae). Name Specialty Street address P.O. box/suite number City State ZIP code Phone number Fax number E-mail address 4. Identify all places of business where the program will be administered and records/claim files maintained. Include contact person (please include any vendors that will be maintaining records/claim files). Do not list a post office box. Network of health care providers 1. Indicate the counties in which the employer is seeking certification. 2. Attach a list of the providers with whom the employer has arrangements for the provision of health care services. BWC-7251 SI-51 American LegalNet, Inc. www.FormsWorkFlow.com The following data elements must be included for each provider within the list and whether they are a companybased provider or network provider: o o o o o o o o Provider name (primary sort key); BWC provider number; Federal tax identification number; Provider type; Provider specialty; Provider address; Provider telephone number; and Provider fax number. Include the above provider data elements and a description of the role of each individual company based provider, as distinguished from QHP network providers. An employer may limit the number of providers on its panel based upon objective data demonstrating the fundamental needs of the employer and employees are met. The employer shall not discriminate against any category of health-care provider when establishing categories of providers for participation pursuant to Ohio Administrative Code (OAC) Rule 4123-6-59. 3. Attach a description of the process, including timeframes, used by the QHP to credential and re-credential medical providers within its panel, or the medical providers seeking to join the panel. 4. Attach a description of the employer's policies and procedures for sanctioning and terminating providers in the panel. Include a description of the QHP's process for notifying BWC, the employer and employees of network changes. 5. Attach a description of the employer's plans for distributing provider directories and updates to BWC, the employer and employees. Medical management and utilization management 1. Attach a description of the employer's methodology for medical management and utilization management to coordinate the delivery of quality, cost-effective medical treatment and to promote an appropriate return to work plan. The description should include the following: o o o o o Explain in narrative form the process for treatment from the point of injury to resolution; include process for referring cases for medical management, including catastrophic cases. Identify any medical case management tools utilized for treatment decisions (i.e. nationally accepted treatment guidelines, DoDM, etc.). Describe your Alternative Dispute Resolution (ADR) process per rule 4123-6-69 for medical disputes. Please submit copies of your determination letters. Describe the role of the Medical Director or Physician Consultant as it relates to participation with the case management process and the ADR process. Pursuant to OAC 4123-6-54 (C) (10), describe the employer's plan in the event that certification of the QHP is revoked or refused by BWC. Specifically, the plan should address the continuity of care to injured workers and payment to providers for medical services rendered prior to the revocation or refusal to certify. Quality assurance and dispute resolution Attach a description of the emplo