Private Review Agent licenses are renewed on July 1st of even-numbered years. The following information must be submitted to the Department by June 30th of even-numbered years. Renewals received after June 30th are subject to administrative disciplinary action. Failure to complete your renewal will prevent your organization from performing utilization reviews in this state.
All signatures and documents must be original. Documents with reproduced or stamped signatures will not be accepted. Faxed documents will also not be accepted. All questions must be thoroughly answered. Improperly completed or incomplete renewals will not be accepted and will be returned.
Application Help Information
Section 1. List major owner(s) and percentage or ownership if organization type is corporation or partnership
Section 2. Attach Certificate of Authority, Letter of Good Standing, or Articles of Incorporation
Section 3. List other organization locations
Section 4. List all partners or officers
Section 5. Provide hours of operation and toll free number
Copy of your "Utilization Review Program"
Provide an accessibility plan of operation for weekends and holidays
Provide both a list indicating the total of all reviewing personnel, by specific qualification or specialty. Additionally, include a total of all physicians, by specialty, which support and/or supervise reviewing personnel
Provide the total number of covered lives for which the reviewing personnel of your company may be required to perform utilization review activities
Provide a copy of all materials designed to inform applicable patients of the requirements of the utilization plan and the responsibilities and rights of patients under each contract
Provide the applicants procedures for notification of an adverse decision. Include all forms used in adverse decision notification process
Provide the applicants appeal procedures by which insured and providers may seek reconsideration of determinations by the applicant’s utilization review personnel. Include all appropriate forms used within the appeals process
Provide the applicants internal procedures currently in place to protect the confidentiality of individual medical records
Specifically list all state and federal laws, which were reviewed by the applicant to develop these procedures