SD EForm - 0815 V1 South Dakota Department of Labor and Regulation Kneip Building, Third Floor 700 Governors Drive Pierre, South Dakota 57501-2277 APPLICATION FOR CERTIFICATION OF MANAGED CARE PLAN ____________________________________________________________ Use this form to certify your managed care plan as required by SDCL 5820-24, 62-5-21, and ARSD chapter 47:03:04. Answer completely the following questions about your managed care plan. If more space is needed, use additional pages (identify your response with the question number). Any supporting documents should be attached to this application. Please return the application by September 30, of plan year. If you have any questions about the information requested, please call (605) 773-3681. ____________________________________________________________ 1. What is your company's name and the address of the place of business where the plan will be administered and records kept? No plan will be certified without a South Dakota place of business. Company Name: Address of Place of Business: City : 2. Incorporation information: State of Incorporation: State: Zip: Date of Incorporation: 3. Contact Person for Managed Care Plan Information: Name: Street or Box #: City: State: Zip: 1 of 15 American LegalNet, Inc. www.FormsWorkFlow.com 4. Day-to-day Administrator of Plan Information: Name: Street or Box # City: Title: Credentials: State: Zip: 5. What are the names and addresses of the officers or directors of the plan or the company that owns the plan? Name Address City State Zip 2 of 15 American LegalNet, Inc. www.FormsWorkFlow.com 6. Does your company operate a managed care, utilization review, or case N management business outside South Dakota? Y If yes, list the states in which you operate such a business and indicate whether the business is certified by any organization or government agency. State of Operation Check if Certified State of Operation Check if Certified 3 of 15 American LegalNet, Inc. www.FormsWorkFlow.com 7. What are the names and credentials of the individuals who will be making final utilization review or medical case management decisions for the plan? The individuals must be licensed, registered, or certified health care providers under SDCL title 36. Name Credentials 8. Will you use a network of participating medical practitioners? Y N If you answered question 8 "Yes," answer questions 9, 10, and 11. If you answered question 8 "No," answer question 12. 9. What are the names, addresses, and specialties of all participating medical practitioners who will provide services under the managed care plan? Attach a statement declaring that the practitioners have complied with any licensing or certification requirements to practice in South Dakota. (Submit attachment if more space is needed) N ame Address City State Zip Specialty 4 of 15 American LegalNet, Inc. www.FormsWorkFlow.com 10. What are your procedures to ensure each participating medical practitioner meets the licensing and certification requirements to practice in South Dakota and to exclude a practitioner whose license is under suspension or has been revoked by the licensing board. 11. Attach a copy of the standard agreement that participating medical practitioner's sign. What other arrangements will you have with medical practitioners to deliver services to employees? 12. What arrangements will you have with medical practitioners to deliver services to employees under your plan since you do not have a provider network? 5 of 15 American LegalNet, Inc. www.FormsWorkFlow.com 13. How will you provide employees prompt and convenient access to health care services as required by ARSD 47:03:04:04? Specifically, how will you make sure employers promptly notify the plan about injuries and employees receive prompt treatment when they request treatment from the plan? What are your procedures for referring an employee to an outside medical practitioner when services are unavailable or are not reasonably accessible within the plan? 14. How will your plan authorize necessary medical services provided by an outside medical practitioner as required by ARSD 47:03:04:05 and 47:03:04:06? Specifically, how will you work with a medical practitioner initially selected by an employee and make sure the medical practitioner complies with the provisions of the rules and the plan? How will you handle emergency treatment? What are your procedures for approving referrals for other treatment or before diagnostic testing? 6 of 15 American LegalNet, Inc. www.FormsWorkFlow.com 15. How will you comply with ARSD 47:03:04:07, which prohibits discrimination against or exclusion from participation in the plan of any category of medical practitioner? 16. Attach the treatment standards your plan has developed to use in reviewing medical services. No plan will be certified without comprehensive treatment standards developed for worker's compensation injuries that have been reviewed and approved by the department. What is the source of your treatment standards? How will the treatment standards be used to review medical services to ensure services are necessary and appropriate? 7 of 15 American LegalNet, Inc. www.FormsWorkFlow.com 17. What are your methods of utilization review to prevent inappropriate, excessive, or medically unnecessary medical services? Explain any preauthorization requirements, concurrent review, or retrospective review that is part of your utilization review program. 18. What are your procedures for excluding medical practitioners who violate your treatment standards from participating in the plan? 8 of 15 American LegalNet, Inc. www.FormsWorkFlow.com 19. How will you develop a treatment plan, monitor the treatment and medical progress of the employee, and make sure that the employee is following the treatment plan? 20. How will you develop a plan for promptly returning an employee to work? 9 of 15 American LegalNet, Inc. www.FormsWorkFlow.com 21. How will you provide for cooperative efforts by employees, employers, and the managed care plan to promote workplace health and safety? 22. How will individuals receive prompt information and advice on the medical services available from your plan and how to access those services on a 24-hour basis using your toll-free telephone service? 10 of 15 American LegalNet, Inc. www.FormsWorkFlow.com 23. What are your procedures for reporting to the employer at least once a month on the medical status and return-to-work status of an emplo