Each certificate application must include:
(1) a description or a copy of the applicant's basic
organizational structure documents and other related documents, including
organizational charts or lists that show:
(A) the relationships and contracts between the applicant
and any affiliates of the applicant; and
(B) the internal organizational structure of the applicant's
management and administrative staff;
(2) a completed biographical affidavit, NAIC UCAA Form
11 (Rev. 12/8/2020), from each person who governs or manages the affairs
of the applicant, including the members of the governing board of
the applicant, the chief executive officer, president, secretary,
treasurer, chief financial officer and controller, and any other individuals
with substantially similar responsibilities, provided that a biographical
affidavit is not required if a biographical affidavit from the person
is already on file with the department;
(3) a copy of the form of any contract between the
applicant and any provider or group of providers as required under
Insurance Code Chapter 1305, Subchapter D, concerning Contracting
Provisions, and §10.41 and §10.42 of this title (relating
to Network-Carrier Contracts and Network Contracts with Providers);
(4) a copy of any agreement with any third party performing
delegated functions on behalf of the applicant as required under Insurance
Code §1305.154, concerning Network-Carrier Contracts, and §10.41
of this title (relating to Network-Carrier Contracts);
(5) a copy of the form of each contract with an insurance
carrier, as described by Insurance Code §1305.154 and §10.41
of this title;
(6) each management contract as described in §10.40
of this title (relating to Management Contracts), if applicable;
(7) a financial statement, current as of the date of
the application that includes the most recent calendar quarter, prepared
using generally accepted accounting principles, and including:
(A) a balance sheet that reflects a solvent financial
position;
(B) an income statement;
(C) a cash flow statement; and
(D) the sources and uses of all funds;
(8) a statement acknowledging that lawful process in
a legal action or proceeding against the network on a cause of action
arising in this state is valid if served in the manner provided by
Insurance Code Chapter 804, concerning Service of Process, for a domestic
company;
(9) a description and a map of the applicant's proposed
service area or areas, with key and scale, that identifies each county,
ZIP code, partial ZIP code, or part of a county to be served;
(10) a description of programs and procedures to be
utilized, including:
(A) a complaint system, as required under Insurance
Code Chapter 1305, Subchapter I, concerning Complaint Resolution,
and Chapter 10, Subchapter G, of this title (relating to Complaints);
(B) a quality improvement program, including return-to-work
and medical case management programs, as required under Insurance
Code Chapter 1305, Subchapter G, concerning Provision of Services
by Network; Quality Improvement Program, and §10.81 of this title
(relating to Quality Improvement Program);
(C) credentialing policies and procedures required
under §10.82 of this title (relating to Credentialing);
(D) the utilization review program described in Insurance
Code Chapter 1305, Subchapter H, concerning Utilization Review, and
Chapter 10, Subchapter F, of this title (relating to Utilization Review),
if applicable; and
(E) criteria and procedures for employees to select
or change the employee's treating doctor, including procedures for
employees to select as the employee's treating doctor a doctor who
the employee selected, prior to injury, as the employee's HMO primary
care physician or provider;
(11) a description of the network configuration that
demonstrates the adequacy of the network to provide comprehensive
health care services sufficient to serve the population of injured
employees within the service area and maps that demonstrate compliance
with the access and availability standards under Insurance Code Chapter
1305, Subchapter G, and §10.80 of this title (relating to Accessibility
and Availability Requirements). This description must include, at
a minimum, the following:
(A) a map for each specialty providing services to
injured employees in accordance with §10.80 of this title, each
of which must include:
(i) each location of health care providers and facilities
within the proposed service area, indicating each location by symbols
of the network's own choosing; and
(ii) the distance from any point in the network's designated
service area to each location;
(B) names; addresses, including ZIP codes; specialty
or specialties; board certifications, if any; professional license
numbers; and hospital affiliations of network providers, including
treating doctors, in sufficient number and specialty to provide all
required health care services in a timely, effective, and convenient
manner;
(C) names; addresses; federal employer identification
number (FEIN); licenses; and types of health care facilities, including
hospitals, rehabilitation facilities, diagnostic and testing facilities,
ambulatory surgical centers, and interdisciplinary pain rehabilitation
programs or interdisciplinary pain rehabilitation treatment facilities.
The network must also demonstrate adequate access to emergency care;
(D) information indicating whether each network provider
is accepting new patients from the workers' compensation health care
network;
(E) information indicating which network doctors are
trained and certified to perform maximum medical improvement determinations
and impairment rating services;
(F) information identifying which network providers
provide telehealth service, telemedicine medical service, or teledentistry
dental service, indicating which of these providers will provide telehealth
service, telemedicine medical service, or teledentistry dental service
only; and
(G) for any service area in which the network does
not meet accessibility and availability requirements described in §10.80
of this title, an access plan that complies with §10.80(a) and
(f) of this title;
(12) the physical location of the applicant's books
and records, including:
(A) financial and accounting records;
(B) investment records;
(C) organizational documents of the applicant; and
(D) minutes of all meetings of the applicant's governing
board and executive or management committees;
(13) a business plan that describes the applicant's
intended operations in this state, including both a narrative description
and projections related to anticipated revenue and profitability for
the first two years of operation after certification;
(14) a completed financial authorization form sufficient
to allow the department to confirm directly with appropriate financial
institutions the reported assets of the applicant, unless the entity
is already licensed by the department;
(15) the applicant's plan for provision of care to
injured employees who live temporarily outside the service area, if
applicable;
(16) the applicant's plan for provision of maximum
medical improvement determinations and impairment rating services,
including verification that the network doctors reported under paragraph
(11)(E) of this section have completed the training and testing required
under Labor Code §408.023, concerning List of Approved Doctors;
Duties of Treating Doctors, and rules adopted by the Commissioner
of Workers' Compensation;
(17) the applicant's plan for obtaining certification
by doctors and health care practitioners of filing the required financial
disclosure with the Division of Workers' Compensation under Labor
Code §408.023 and §413.041, concerning Disclosure;
(18) the form of the notice of network requirements
and employee information, and the acknowledgment form required under
Insurance Code §1305.005, concerning Participation in Network;
Notice of Network Requirements, and §10.60 of this title (relating
to Notice of Network Requirements; Employee Information);
(19) the applicant's plan for monitoring whether providers
have been provided and are following treatment guidelines, return-to-work
guidelines, and individual treatment protocols as required under Insurance
Code §1305.304, concerning Guidelines and Protocols, and §10.83
of this title (relating to Guidelines and Protocols);
(20) a description of treatment guidelines and return-to-work
guidelines, and the network medical director's certification that
the guidelines are evidence-based, scientifically valid, and outcome-focused,
and be designed to reduce inappropriate or unnecessary health care
while safeguarding necessary care, as required under Insurance Code §1305.304
and §10.83(a) of this title; and
(21) a certification that:
(A) the network's medical director is an occupational
medicine specialist; or
(B) the network employs or contracts with an occupational
medicine specialist.
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