1200-8-33-.02 REVIEW OF CERTIFICATE OF AUTHORITY APPLICATIONS.

1200-8-33-.02 REVIEW OF CERTIFICATE OF AUTHORITY APPLICATIONS.

(1) When a health maintenance organization applies to the Department of Commerce and Insurance for a Certificate of Authority, the health maintenance organization shall submit documentation to the Tennessee Department of Health, Division of Health Care Facilities, demonstrating to the Commissioner of Health, or the Commissioner's designee, proof of capability to provide or arrange for the provision of basic health care services efficiently, effectively and economically and to ensure that the HMO provider network can reasonably be expected to meet its obligations to enrollees and prospective enrollees. The applicant shall meet the network adequacy requirements established pursuant to T.C.A. 56-7-2356. (This provision does not apply to applicants intending only to conduct a TennCare Program Line of Business. Network adequacy review for TennCare Program Lines of Business is conducted by the TennCare Bureau). The Commissioner of Health shall report such commissioner's findings to the Commissioner of Commerce and Insurance, who may then deny the application for a certificate of authority, as provided in T.C.A. 56-32-204 and 56-32-218(b). In order to meet the requirements, the HMO must have the capability to provide basic health care services (or additional health care services, as applicable) efficiently, effectively and economically. The health maintenance organization shall submit the following for review:

(a) Copy of the Application for Certificate of Authority and accompanying documentation submitted to the Department of Commerce and Insurance, including:

1. Copy of the organizational documents of the applicant;

2. Copy of the by-laws;

3. Biographical data on corporate officers and directors;

4. Sample copy of contracts between the health maintenance organization and participating providers (primary care physicians, physician specialists, hospitals, etc.);

5. Copy of the form of Evidence of Coverage to be issued to members;

6. Copy of the form or group contract, if any, to be issued to employers, unions, trustees, etc.;

7. Detailed description of the complaint and grievance procedure to be used; and

8. Description of the proposed method of marketing, including advertising material to be used in soliciting subscribers.

(b) Other information to demonstrate the applicant's proof of capability to provide basic health care services (or additional health care services, as applicable) efficiently, effectively and economically, including:

1. Location of proposed operational sites and hours of operation;

2. Organizational chart showing key personnel, (chief executive officer, medical director, quality improvement director, utilization management director, etc.) and the delegation of authority and control of the health care delivery system;

3. List of counties in the proposed service area and projected member enrollment by county;

4. List of contracting physicians, hospitals, pharmacies, and other providers in the proposed service area, categorized by county, including the provider's name, location (city), and specialty (if applicable);

(i) This list is to be submitted to the Division of Health Care Facilities for review when the health maintenance organization has signed contracts with such providers. After the network has been reviewed, an on-site visit will be scheduled to verify the signed contracts. This on-site visit will occur when the health maintenance organization has an adequate number of members to evaluate the operation of the health maintenance organization.

5. Descriptions of the quality improvement program and the utilization management program;

6. Member handbook (or description of member policies and procedures);

7. Physician application form and a description of the policies and procedures used to approve and ensure the credentials of said Physicians;

8. Physician handbook (or description of physician policies and procedures);

9. Description of the payment methodology for primary care physicians and physician specialists; and

10. Job description and work schedule for the medical director and medical director's curriculum vitae.

(c) Any other information that the Department determines is needed to demonstrate the applicant's proof of capability to provide basic health care services (or additional health care services, as applicable) efficiently, effectively and economically.

(2) The review process by the Division of Health Care Facilities shall consist of a review of the medical management, quality improvement, utilization management, and other programs and a review of the network of hospitals, physicians, pharmacies, and other providers in the proposed service area. When the health maintenance organization has developed a provider network and has signed contracts, it shall submit a list of contracting physicians, hospitals, pharmacies, and other providers, categorized by county, including the provider's name, location (city), and specialty (if applicable). The network will be reviewed and an on-site visit will be scheduled to verify the signed contracts.

(3) When the review has been completed a letter shall be sent to the Department of Commerce and Insurance indicating whether or not the health maintenance organization's proposal meets the requirements of the Department of Health.

Authority: T.C.A. 4-5-202, 4-5-204, 56-32-203, 56-32-204, 56-32-215, 56-32-218, and 68-1-103. Administrative History: Original rules filed April 14, 2003; effective June 28, 2003.



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