N.J. Admin. Code § Tit. 11, ch. 24B, APPENDIX, exh. 2

Current through Register Vol. 56, No. 21, November 4, 2024

Exhibit 2

New Jersey Department of Banking and Insurance Application

Checklist for ODS Certification or Recommendation for License

Please use this checklist to complete the application package. Refer to N.J.A.C. 11:24B-2.2, 2.3, and 2.4 for more detailed instructions (applicants for license should refer also to N.J.A.C. 11:22-4). Applications should be mailed to: ODS Certification, New Jersey Department of Banking and Insurance, Market Regulation, P.O. Box 329, Trenton, NJ 08625-0329; street address: 20 West State Street, 9th Floor, Trenton, NJ 08625.

Part A

(11:24B-2.3)

1.... A completed Application Cover Sheet

2.... A completed Irrevocable Consent to Jurisdiction of the Commissioners and New Jersey Courts

3.... A completed Appointment of Attorney for the State of New Jersey

4.... A completed Financial Risk Affidavit (applicants for certification only)

5.... A copy of the ODS's basic organizational documents, as defined at 11:24B-1.2

6.... A copy of the ODS's executed by-laws, plan of operation, rules and regulations, or similar documents intended to regulate the conduct of the ODS's internal affairs

7.... A Biographical Affidavit completed for each of the individuals who are, or are intended to be, responsible for the conduct of the affairs of the ODS, including:

i) members of the ODS's board of directors, executive committee or other governing board or committee;

ii) the ODS's principal officers, and medical director, if applicable;

iii) any person who owns or has the right to acquire 10 percent or more of the voting securities of the ODS;

iv) each person that has loaned funds to the ODS for the operation of the ODS's business; and

v) partners or members, in the case of a partnership or association

8.... A business plan consisting of:

(i) an organizational chart of the ODS

(ii) a narrative description of the ODS, its facilities, and personnel, and the health care services to be offered by the ODS to a carrier;

(iii) a list of the geographical areas in which the described health care services are to be performed and approximate number of each type of provider who will provide the health care services;

(iv) a description of any administrative services for which the ODS shall be responsible on behalf of the carrier;

(v) a list of any affiliate of the ODS that provides services to the ODS in New Jersey and a description of any material transaction between the affiliate and the ODS;

(vi) a description of any arrangements between the ODS and any other ODS or subcontractor for services associated with the provisions of health care services;

(vii) a description of any reinsurance or stop loss arrangements;

(viii) a plan, in the event of insolvency of the ODS, for continuation of the health care services to be provided in accordance with existing contracts and laws;

(ix) a description of the means by which the ODS will be compensated under contracts with carriers;

(x) a description of the arrangement for the ODS reporting of data to the carriers and a description of the carrier's oversight responsibility.

9.... A specimen copy of all provider agreements made or intended to be executed between the ODS and providers

10.... A specimen copy of all contracts made or intended to be executed between the ODS and any other ODS or subcontractor for services associated with the provision of health care services

11.... A specimen copy of all management agreements made or to be executed between the ODS and one or more carriers

12.... A list of all administrative, civil or criminal actions and proceedings to which the ODS, its affiliates, or persons who are responsible for the conduct of the affairs of the ODS or affiliate, have been subject, including a statement regarding the resolution of such actions and proceedings.

13.... A list of the carriers with which the ODS has contracted or intends to execute a contract pending the approval of the application

14.... A list of all states in which the ODS has been or currently is doing business as described in the application

15.... The appropriate fee set forth at 11:24B-2.9

Part B

(11:24B-2.4)

1.... Services for which certification is being sought (please circle all that apply):

(1) Performance of one or more types of health care services delivery

(2) Network management

(3) Credentialing and recredentialing

(4) Utilization management development

(5) Utilization management application

(6) Utilization management appeals

(7) Member complaints

(8) Provider complaints

(9) Continuous quality improvement

2.... For performance of one or more types of health care services delivery:

(a)... List of names of all providers by county, municipality, zip code, and services

(b)... Map of the service area identifying the location of the participating providers

(c)... Criteria to assure the availability and accessibility of services to be performed

3.... For network management:

(a)... Demonstration of adequacy of the network for services offered in relation to population to be served consistent with standards of 11:24B-3.5

(b)... Demonstration of the CQI program

(c)... Demonstration of the complaint and appeal system for providers

(d)... Demonstration of the provider participation panel

(e)... Demonstration of the hearing panel for provider terminations

(f)... Demonstration of records maintenance procedures and standards

(g)... Credentialing and recredentialing standards

(h)... Statement of deficiencies and POCs with respect to licensed facilities

4.... For credentialing and recredentialing:

(a)... Policies and procedures, demonstrating compliance with 11:24B-3.6

(b)... Designated medical director and his/her functions

(c)... Explanation of linkage and coordination with the CQI and complaint systems of the carrier(s) and/or their other contractor(s), including flow chart(s)

5.... For utilization management development:

(a)... Policies and procedures for developing protocols and guidelines, demonstrating compliance with 11:24B-3.7

(b)... Designated medical director and his/her functions

(c)... Copy of the protocols and guidelines developed, and instructions for use

6.... For performance of utilization management:

(a)... Policies and procedures, demonstrating compliance with 11:24B-3.8

(b)... Designated medical director and his/her functions

(c)... Explanation of medical director's oversight, if employed by the carrier

(d)... Explanation of the UM criteria used

7.... For utilization management appeals:

(a)... Policies and procedures, demonstrating compliance with 11:24B-3.9

(b)... Designated medical director and his/her functions

(c)... Flow chart demonstrating communication and decision-making, if the medical director is employed by the carrier

(d)... Specimens of letters regarding appeal rights and decisions on appeals to be sent to both covered persons and providers.

8.... For member complaints:

(a)... Policies and procedures, demonstrating compliance with 11:24B-3.1 2

(b)... Explanation of linkage and coordination with the CQI and complaint system of the carrier(s) and/or their other contractor(s)

(c)... Explanation of how complaints are segregated among carriers (and other clients)

(d)... Specimens of the letters regarding complaint and complaint resolution to be sent to covered persons and providers acting on behalf of covered persons

9.... For provider complaints:

(a)... Policies and procedures, demonstrating compliance with 11:24B-3.1 1

(b)... Explanation of linkage and coordination with the CQI and complaint system of the carrier(s) and/or their other contractor(s)

(c)... Explanation of how complaints are segregated among carriers (and other clients)

(d)... Specimens of the letters regarding a complaint and complaint resolution to be sent to providers.

10.... For continuous quality improvement:

(a)... Policies and procedures, demonstrating compliance with 11:24B-3.10

(b)... Explanation of linkage and coordination with the complaint systems and other continuous quality improvement components that the carrier(s) may have

(c)... Designated medical director and his/her functions

Part C

(11:24B-2.2)

1.... Application in 3-ring binder(s), labeled with the ODS' name, and serially numbered, if necessary

2.... Application tabbed, exhibits segregated, and shown in order requested in regulations

3.... All pages numbered

4.... All specimen contracts contain unique identifier in lower left corner of each page

5.... Payment by check or money order made payable to the Treasurer, State of New Jersey

6.... No items left blank

N.J. Admin. Code Tit. 11, ch. 24B, APPENDIX, exh. 2

Amended by 55 N.J.R. 1186(a), effective 6/5/2023