Free APPLICATION FOR CERTIFICATION OF A CARRIERS= - Michigan

APPLICATION FOR CERTIFICATION OF A CARRIER'S PROFESSIONAL HEALTH CARE REVIEW PROGRAM
Michigan Department of Energy, Labor & Economic Growth Workers' Compensation Agency Health Care Services Division PO Box 30016, Lansing, Michigan 48909

Date of Application

Initial

Renewal



Note: A new application must be submitted whenever there is a change in carrier, service company, or review company. This form is required in accordance with Part 12, R 418.101206 of the Workers' Compensation Health Care Services Rules to receive certification of a carrier's professional review program.

I. CARRIER
Carrier
NAIC No., Self-Insured No., or FEIN Name Address (Street) City, State, Zip Code Telephone No. (Include area code) Contact Person and Email Address

Service Company
Agency Assigned Number Name Address (Street) City, State, Zip Code Telephone No. (Include area code) Contact Person and Email Address

Review Company
Employer Identification Name Address (Street) City, State, Zip Code Telephone No. (Include area code) Contact Person and Email Address

II.

METHODOLOGY/REVIEW STAFF AND CREDENTIALS

Attach methodology, according to the workers' comp agency procedure, used to perform a carrier's professional review. R 418.101204(5)(a)-(c) requires that medical appropriateness of services shall be determined through one of the following approaches: 1) Review by licensed, registered, or certified health care professionals. 2) The application by others of criteria developed by licensed, registered, or certified health care professionals. 3) A combination of (1) and (2) according to the type of covered injury or illness. The methodology should include a list of all licensed, registered, or certified health care professionals reviewing case records and medical bills for the above carrier. Provide current licensure information (license #, state of issue, date of expiration and restrictions) and qualifications for medical bill review. In addition, include a list of all peer reviewers with current license information and specialty. *When a service company submits applications for numerous self-insured employers, and the methodology is identical, it is not necessary to submit the professional review methodology more than once. The Workers' Compensation Agency will maintain on file, the review methodology for each service company. **Methodology for professional certification must be submitted once every three years or whenever changes occur.

III. AUTHORIZED SIGNATURE
By signing this form, I certify that the information included on this form is correct and complete to the best of my knowledge and that the professional review methodology is attached or has already been submitted by the service company and/or their designated agent. I understand that submitting false information is cause for denial of the application or will subject me to penalties as provided by law. Authorized Signature (In Ink) Authorized Name and Email Address (Typed) Date

Alternate Person Name

Alternate Email Address

Alternate Telephone Number

DELEG is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-590 (Rev. 6/09)