Free Application Instructions - Massachusetts

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THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET - 7TH FLOOR, BOSTON, MA 02111 (617) 727-4900
APPLICATION FOR APPROVAL UTILIZATION REVIEW AND QUALITY ASSESSMENT PROGRAM ("PROGRAM") 452CMR 6.00 et seq.
INSTRUCTIONS

Applicants must be familiar with the content and intent of 452 CMR 6.00 in order to complete this document. Terms and definitions therein should be applied consistently throughout the application and in all exhibits. The application, all exhibits and any revisions to the application must be typewritten (or machine printed), each page numbered sequentially, and sent electronically and via hardcopy to: Department of Industrial Accidents c/o Executive Director Office of Health Policy 600 Washington Street, 7th Floor Boston, MA 02111
PROCESS

The application will be reviewed by the Office of Health Policy ("OHP"), and the applicant notified by the Department of Industrial Accidents ("Department") of approval or non-approval of the application within forty-five (45) days of receipt. If the Department is unable to approve the application, the applicant may be asked to submit additional information and/or to meet with Departmental staff. Any resubmission of the application shall be deemed a new Application for Approval and the applicant will be notified of approval or non-approval within forty-five (45) days. If the application is not approved after the second revision, the applicant may appeal the decision by submitting a written request for appeal to the Commissioner of the Department within thirty (30) days of receipt of notice of non-approval. The request shall set forth the reasons for the appeal along with any documentation in support of the appeal. The Commissioner or his designee shall hold a hearing pursuant to M.G.L. c. 30A. Applicants who are approved by the Department shall receive an agent identification number and a two year Certificate of Approval. Any material change to the Utilization Review Program shall be submitted for review and approval by the Department within thirty (30) days of the change. The written changes must be paginated and will be inserted and incorporated into the existing, approved application. A separate application must be completed for each site within the organization/corporation conducting utilization review(UR) for the Massachusetts Workers' Compensation Program. Each site will be approved as a separate UR Agent within the organization/corporation. All documents and information provided by the applicant are subject to disclosure under the provisions of the Public Records Statute, M.G.L. c.66. I. CORPORATE & SITE DEMOGRAPHICS In the spaces below, identify the entity seeking approval to conduct utilization review and the program's address as it should appear on the Certificate of Approval. Company name, including "doing business as" ("dba") must be supported by articles of incorporation or other legal documentation submitted with application. The name listed here must be consistent with the primary name of applicant's company. If you want to use other corporate names on your certificate, you must submit with your application the appropriate legal documentation for such other corporate names. The information in sections A, B, D, (#2 and 3 only) will be included in a list made public by the Department.

Date Application Submitted: __________________ A. B. C. Name of Applicant:__________________________________________________________________ Name of the Program or D.B.A.: _______________________________________________________ Location/Site where UR is Conducted:___________________________________________________ ___________________________________________________
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D.

Applicant's Program contact(s): 1. The Program's Corporate Contact: a) Name: ______________________________________________________________________ b) Title: _______________________________________________________________________ c) Address: ____________________________________________________________________ d) Telephone: _________________ e) Fax: __________________ f) Toll-Free #: _________________ g) Email: ______________________________________ 2. The Program's Massachusetts Contact: a) Name: ______________________________________________________________________ b) Title: _____________________________________________________________________ c) Address: _____________________________________________________________________ d) Telephone: _________________ e) Fax: ___________________ f) Toll-Free #: _________________ g) Email: _____________________________________ 3. The Program's Public Contact: a) Name: ______________________________________________________________________ b) Title: _____________________________________________________________________ c) Address: _____________________________________________________________________ d) Telephone: _________________ e) Fax: ____________________ f) Toll-Free #: _________________ g) Email: ______________________________________ 4. Toll free telephone and fax numbers for the Program (to be provided to injured employees): a) Toll-Free #:___________________ b) Fax #: ___________________

Exhibit A Has the applicant been approved to perform Utilization Review for workers' compensation in other states? Yes - list state(s) II. TREATMENT GUIDELINES & REVIEW CRITERIA: A. The applicant will use the Health Care Services Board ("HCSB") endorsed Treatment Guidelines for all conditions where they apply? Yes No Identify all secondary sources of treatment guideline(s) to be used for medical conditions not covered by MA Treatment Guidelines: 1. ________________________________________________________________________ 2. 3. 4. 5. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Other: __________________________________________________________________ No

B.

Exhibit B Describe how the applicant's internally derived treatment guideline(s) and review criteria are developed and revised, including: 1. The role of the medically qualified Practitioner(s) who is/are involved in the development of the internally derived treatment guideline(s) and review criteria;
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2. Internally derived treatment guideline(s) and review criteria shall be maintained in a format similar to the format of the MA Treatment Guidelines. 3. Internally derived treatment guideline(s) and review criteria shall be reviewed and necessary revisions made at least annually. 4. Internally derived treatment guidelines shall be developed through the use of clinically based literature and scientific research. Exhibit C Describe how each of the secondary sources above will be applied to review the treatment of injured employees. Exhibit D Provide a detailed narrative of the applicant's procedures for conducting prospective, concurrent, and retrospective UR from initial request through final complaint to DIA. Incorporate the Departments' recommended
clinical procedures relating to clinical review time frames for each type of review and collection of additional information. (Recommended clinical review procedures available on the Departments web site www.state.ma.us/dia see the OHP link to the application. Copies of all correspondence directed to the ordering provider should also be sent to the injured worker).

Exhibit E A. Describe the process for notification of adverse determinations to the ordering practitioner and injured employee/representative. B. Provide a detailed description of the adverse determination process that includes MA Treatment Guidelines applied by the applicant and the clinical rationale for reaching the determination.

Exhibit F Provide a detailed description of both standard and expedited appeal procedures by which an ordering practitioner and/or injured employee may seek review of the applicant's utilization review determination(s). Exhibit G Provide a detailed description of the applicant's internal quality assessment and monitoring process, and how it will evaluate and measure the quality of its Program. Provide any and all internal or external audit processes of the determinations made by all level reviewers including subcontractors. 2) Provide list of all licensed reviewers their license number and category, state of licensure, expiration date, and letter of attesting to number of hrs in active practice. 3) Provide an outline of formal training requirements for each level of clinical reviewer and administrative staff. 4) Provide policies and procedures regarding documentation of the review process, (case notes and summaries, referral forms etc.). 5) Provide a copy of organizational flow chart for the utilization management department indicating reporting/supervisory relationships, corporate organizational chart, and table of sub-specialties of clinical reviewers. 6) Provide a copy of your grievance/complaint procedures for injured employees (a copy of any grievance/complaint received by the UR agent must be forwarded to the DIA OHP within ten days of its receipt). A. Does the applicant have written/printed materials used in marketing, advertising and promoting its program to employers, insurers and others? Yes ­ please attach samples No Does the applicant provide additional services, other than those approved by the Department, as part of the applicant's business? If yes, list all additional services provided and provide a detailed narrative
description of how these services are delineated from the applicant's utilization review program (other than MA WC UR and claims)

B.

Yes

No

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C.

Will the applicant provide any economic incentive(s) to achieve cost savings in its program? Yes - Explain No Case management is considered an ancillary service in Massachusetts Workers' Compensation. If case management services are provided, the applicant agrees that clinical reviewers will not conduct case management of the same case(s) they are providing utilization review. Yes No ­ Explain

D.

III.

UTILIZATION REVIEW NOTIFICATIONS, DETERMINATIONS AND APPEAL PROCEDURES: Exhibit H A. Provide clearly marked sample copies of the letters (on business letterhead) that the applicant will use to conduct its business as a Utilization Review Agent pursuant to 452 CMR 6.00 et seq.., which should include, but not be limited to, a Letter of Introduction that includes and introductory paragraph to the injured employee and a paragraph that outlines the utilization review complaint process that addresses complaints against the actions or inactions of UR Agents, information regarding ID card that should have been receive from the insurer/adjuster and if not received, who to call and telephone number to request the ID card; Approved Determination letter that includes introductory paragraph and MA treatment guidelines or secondary source(s) used to approve health care service(s); Adverse Determination letter that includes introductory paragraph, MA treatment guideline or secondary source(s), clinical rationale, name and school of school to school reviewer and appeal/complaint process; Adverse Determination letter upholding an initial adverse determination that includes introductory paragraph, MA treatment guideline or secondary source(s) clinical rationale, name and school of school to school reviewer and process to file for further appeal or to file a claim for payment with the DIA. Approved Appeal letter that includes introductory paragraph, MA treatment guidelines or secondary source and clinical rationale. Other letters and forms to be included; Letter requesting additional medical information, form for referral to same school reviewer. B. The Office of Health Policy requires the following paragraph be included in the body of all mandated introductory letters to injured workers in accordance with 452 CMR 6.00 et seq.: If at any time an injured employee, ordering provider, or employee representative believes the utilization review agent's conduct to be in violation of the Code of Massachusetts Regulations, 452 CMR 6.00 et seq., a complaint may be filed with the Department of Industrial Accidents by contacting the Department by phone at (617) 727-4900 x438 and requesting a UR agent complaint form (133A). A copy of this form is posted on the Department's website at www.state.ma.us/dia

IV.

REVIEWER CREDENTIALING PROCESS Exhibit I A. Provide a detailed description in narrative form of the applicant's credentialing/re-credentialing procedures for its medical director and/or clinical director, school to school reviewers, registered nurses, and all other clinical reviewers that includes, but is not limited to, credentialing/re-credentialing procedures that ensure that all clinical review staff are properly qualified and credentialed to provide clinical opinions, board certification (if applicable), and a description of both the initial and on-going process for verification of the credentials of the applicant's reviewers. B. Provide job descriptions for all employees performing non-licensed administrative functions for the utilization management department.

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C. List of reviewers conducting reviewers at all levels of the review. List the name, license category and registration number/board certification number and state of licensure for each reviewer conducting any level of review, including the medical director. D. Provide job descriptions for the medical/clinical director who provides medical oversight for clinical reviews. The medical director's job description should include licensure and board certification requirements. E. Job descriptions for all levels of clinical reviewers that indicates the clinical reviewer will be in active practice at least 8 hours per week, and includes level of licensure. F. If any part of the applicant's credentialing/re-credentialing procedures is subcontracted the applicant should provide a description of the applicant's procedure for monitoring of the sub-contractor's credentialing procedures which may include, but is not limited to, policies and procedures that provide for periodic review of the sub-contractor's performance, and copies of the sub-contractor's credentialing procedures. V. TELEPHONE SYSTEM A. Indicate the days and hours (EST) of operation during which the applicant's reviewers will be available to perform Utilization Review: Must be at least 9am - 5pm EST. HOURS Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Exhibit J Describe the applicant's system for receipt of telephone calls and messages during non-business hours. This line must be confidential line within the UR department. Exhibit K Describe the applicant's toll-free telephone script(s) - including holidays, weekends and non-business hours, automated call distribution greetings, recorded messages, and/or live script(s) specific to the Program.

VI.

VII. GENERAL REQUIREMENTS Exhibit L A. Include the applicant's written policies and procedures for assuring the confidentiality of injured worker specific information obtained during the Utilization Review process. Does the applicant have professional and general liability coverage at limits of not less than one million dollars per occurrence? Yes No - Explain Exhibit M List all Insurers, Self-Insurers, Third Party Administrators (all entities) whom the applicant contracts with. Exhibit N List all entities with whom the applicant will sub-contract for the provision of some portion(s) of the applicant's Program and provide a detailed narrative description of the Program's monitoring procedures for the oversight of sub-contractors. B.

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VII.

CERTIFICATION

By the signature of the authorized representative below, the applicant certifies it has read and understands 452 CMR 6.00 et seq. and shall comply with all applicable Massachusetts and Federal Laws, including, but not limited to, those laws which protect the confidentiality of medical records. In addition, the undersigned certifies that all other information provided with this application is neither falsified nor fraudulent. BY: Name of Applicant: Name/Title of Authorized Representative: Date: _____________ __________________________________________ __________________________________________ Signature of Authorized Representative: _____________________________________________ Current MA UR Agent Identification Number: _________________________________________
FEIN #__________________

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