§ 9771.62. Application for Authorization as a Workers' Compensation Health Care Provider Or...
8 CA ADC § 9771.62Barclays Official California Code of Regulations
8 CCR § 9771.62
§ 9771.62. Application for Authorization as a Workers' Compensation Health Care Provider Organization.
DIVISION OF WORKERS' COMPENSATION
SUPPLEMENTARY APPLICATION
UNDER LABOR CODE SECTION 4600.6.Date of Application:
WORKERS' COMPENSATION HEALTH CARE PROVIDER
ORGANIZATION AUTHORIZATION APPLICATION
LABOR CODE SECTION 4600.6 (EXECUTION PAGE)Identification of Organization.
Name of Applicant.
a. Legal name:
Additional Exhibits: An original application for organization authorization must include the completed form specified in this subsection and the exhibits required.
1. Summary Description of Organization and Operation. Provide as Exhibit C-1 a summary description of the organization and operation of applicant's business as a workers' compensation health care provider organization, covering the highlights and essential features of the information provided in response to the other portions of this application which is essential or desirable to an effective overview of the applicant's workers' compensation health care business, including a summary of the applicant's experience in the provision of workers' compensation health care.
2. Summary Description of Start-up. Provide as Exhibit C-2 a concise description of applicant's start-up program and its assumptions, including such program's operating, capitalization and financial assumptions. Indicate applicant's projected date for the beginning of operations, and discuss the factors which require such date.
a. Corporation. If applicant is a corporation, attach as Exhibits D-1-a-I, D-1-a- ii, D-1-a-iii and D-1-a-iv respectively, the Articles of Incorporation, Bylaws, the Corporation Information Form (Form WCHCPO 1-A) and any other organizational documents or agreements relating to the internal affairs of the applicant.
d. Other Organization. If applicant is any other type of organization, attach as Exhibit D-1-d Articles of Association, trust agreement, or any other applicable documents, and any other organizational documents or agreements relating to the conduct of the internal affairs of the applicant, and attach as Exhibit D-1-d-ii the Information Form for other than Corporations, Partnerships, and Sole Proprietorships. (Form WCHCPO 1-D)
a. Persons to Be Identified. Attach as Exhibit D-2-a, a list identifying each individual or entity who is a party to a contract with applicant, if such contract is one for the provision of administrative services to the applicant or any such party is an Affiliated Person or Principal Creditor (Rule 9771.60( c) and (j)) of the applicant. As to each such person, show the following information in columnar form:
If the appropriate response to this item is “yes,” attach as Exhibit D-3 a statement identifying each such person or entity and explaining fully such person's power or control, and summarizing every contract or other arrangement or understanding (if any) with each such person. (Each such contract should be submitted pursuant to Subsection D-2.)
4. Criminal, Civil and Administrative Proceedings. Within the preceding 10 years, has the applicant, its management company, or any Affiliate of the applicant (Rule 9771.60(c)), or any controlling person, officer, director or other person occupying a principal management or supervisory position in such organization, management company or Affiliate, or any person intended to hold such a relationship or position, been convicted of or pleaded nolo contendere to a crime, or been held to have committed any act involving dishonesty, fraud or deceit in a judicial or administrative proceeding to which such person was a party?
If “yes,” attach a separate exhibit as to each such person designated Exhibit D-4, identifying such person and fully explaining the crime or act committed. Also, attach a copy of the exhibit to any Individual Information Sheet required by Item D-1-e for such individual.
5. Employment of Barred Persons. Has the organization engaged or does the organization intend to engage, as an officer, director, employee, associate, or provider, any person named in (i) any order of the Commissioner pursuant to Section 1386(c) or Section 1388(d) of the Knox-Keene Health Care Service Plan Act of 1975, (ii) any similar order of the Insurance Commissioner under the Insurance Code barring or otherwise prohibiting such person from being employed or otherwise engaged as an officer, director, employee, associate or provider of any entity subject to the jurisdiction of the Insurance Commissioner, or (iii) any administrative orders issued by a professional licensing board or by the Department of Industrial Relations? If the appropriate response to this item is “yes,” attach as Exhibit D-5 a statement identifying each such person and explaining fully the scope of, and the circumstances giving rise to, such order.
Section | 4600.6(g) | |||
4600.6(I)(8) | ||||
4600.6(n) | ||||
Rules | 9771.69 | |||
9771.70 | ||||
9772 through 9778 |
Compliance with Requirements. Attach as Exhibit F a schedule in tabular form for each workers' compensation health care contract and each standard form workers' compensation contract, identifying the particular provision of such contract which complies with the sections listed below, covering also any variations made in standard form contracts. As to any provision which varies from the applicable provision of the Act or rules, identify such provision in Exhibit F.
Section | 4600.5(e)(7)(B) | |||
4600.6(e) | ||||
Rules | 9771.67 | |||
9771.69 | ||||
9772 - 9778 |
Attach as Exhibit G a copy of any advertising which is subject to Section 4600.6 of the Code and which applicant proposes to use. With respect to each proposed advertisement indicate the contract(s) by name and by exhibit number(s) to which such advertisement relates and identify the employer segment to which the advertisement is directed.
Attach as Exhibit H a statement describing the methods by which applicant proposes to market workers' compensation health care contracts, including the use of employees, or contracting solicitors or solicitor firms, their method or form of compensation, and the methods by which applicant will obtain compliance with Rules 9771.64, 9771.65, and 9771.83.
Attach as Exhibit I a statement setting forth applicant's internal arrangements to supervise the marketing of its workers' compensation health care contracts, including the name and title of each person who has primary management responsibility for the employment and qualification of solicitors, advertising, contracts with solicitors and solicitor firms and for monitoring and supervising compliance with contractual and regulatory provisions.
1. Attach as Exhibit J-1 a list of all persons (other than any employee of the organization whose only compensation is by salary) soliciting or agreeing to solicit the sale of workers' compensation health care contracts on behalf of the applicant. For each such person, identify by exhibit number that person's contract furnished pursuant to Item K-2 and, if such contract does not show the rate of compensation to be paid, specify the person's rate of compensation.
2. Attach as Exhibit J-2, a copy of each contract or proposed contract between applicant and the persons named in Exhibit J-1 for soliciting the sale of or selling workers' compensation health care contracts on behalf of applicant. If a standard form contract is used, furnish a specimen of the form, identify the provision and terms of the form which may be varied and include a copy of each variation.
Note: All projections are to cover the period commencing from the applicant's commencement of operations as an authorized and certified workers' compensation health care provider organization for two years.
1. Projections. Attach as Exhibit K-1 projections of applicant's enrollments under workers' compensation health care provider contracts with self-insured employers, groups of self-insured employers, or insurers of employers (individually, “Employer”; collectively, “Employers”) for the periods specified in the above note. Exhibit K-1 is to contain the following information with respect to each anticipated workers' compensation health care contract:
2. Substantiation of Projections. Attach as Exhibit K-2 for each workers' compensation health care contract specified in Exhibit K-1 a description of the facts and assumptions used in connection with the information specified in that exhibit and include documentation of the source and validity of such facts and assumptions.
b. If the financial statements attached as Exhibit M-1-a are for a period ended more than 60 days before the date of filing of this application, also attach as Exhibit M-1-b financial statements prepared as of date no later than 60 days prior to the filing of this application consisting of at least a balance sheet, a statement of income and expenses, and any accompanying footnotes; these more recent financial statements need not be audited, so long as they are prepared in accordance with generally accepted accounting principles.
2. Provision for Extraordinary Losses. The following requirements require an initial applicant to submit legible copies of the actual policies of insurance (including any riders or endorsements) or specimen copies of the policies of insurance which show all of the terms and conditions of coverage, or with respect to those items expressly allowing for self-insurance, allow applicant to provide evidence of self-insurance at least as adequate as insurance coverage.
b. Attach as Exhibit M-2-b evidence of adequate insurance coverage or self-insurance (e.g., appropriate reserve set aside to fund likely liabilities associated with uninsured costs) to respond to claims for tort claims, other than with respect to claims for damages arising out of furnishing health care services.
c. Attach as Exhibit M-2-c evidence of adequate insurance coverage or self-insurance to protect applicant against losses of facilities upon which it has the risk of loss due to fire or other causes. Identify facilities covered by individual policies and indicate the basis upon which applicant believes that the insurance thereon is adequate.
d. Attach as Exhibit M-2-d, evidence of fidelity bond coverage for at least the amounts specified in Rule 9771.74, in the form of a primary commercial blanket bond or a blanket position bond written by an insurer licensed by the California Insurance Commissioner, providing 30 days' notice to the Administrative Director prior to cancellation, and covering each officer, director, trustee, partner and employee of the organization, whether or not compensated.
2. Provider Claims. Attach as Exhibit N-2 a statement describing applicant's system for processing claims from providers for payment, including the rules defining applicant's obligation to reimburse, the standards and procedures for applicant's claims processing system (including receipt, identification, handling, screening, and payment of claims), the timetable for processing claims, and procedures for monitoring the claims processing system.
3. Other Business. If the applicant is or will engage in any business other than as a workers' compensation health care provider organization, attach as Exhibit N-3 a statement describing such other business, its relationship to applicant's business as an organization, and the anticipated financial risks and liabilities of such other business. If the financial statements and projections in Exhibits M-1-a, do not include such other business, explain.
2. State of Incorporation.
3. Date of Incorporation.
6. Names of principal officers, directors and shareholders: List (a) each person who is a director or principal officer or who performs similar functions or duties and (b) each person who holds of record or beneficially 5 percent or more of the voting securities of applicant or 5 percent or more of applicant's equity securities. If this is an amended exhibit, place an asterisk (*) before the names for whom a change in title, status or stock ownership is being reported and a double asterisk (**) before the names of persons which are added to those furnished in the most recent previous filing.
Full Name Last First Middle | Relationship Beginning Date Mo. Year | Class of Equity Title or Security Status | Percent of Class |
STATE OF CALIFORNIA
DIVISION OF WORKERS' COMPENSATIONEXHIBIT D-1-ii PARTNERSHIP
INFORMATION FORM
To be used in response to Item D-1-b of Form WCHCPO 1.
1. Name of Applicant (as in Item 1-a).
2. State of organization.
3. Date of organization.
4. Names of Partners and Principal Management: List all general, limited and special partners and all persons who perform principal management functions. If this is an amended exhibit, place an asterisk (*) before the names of persons for whom a change in title, status or partnership interest is being reported and place a double asterisk (**) before the names of persons which are added to those furnished in the most recent previous filing.
Full Name Last First Middle | Beginning Date Mo. Year | Type of Partner | Capital Contribution (percentage) | Title or Duties | |
STATE OF CALIFORNIA
DIVISION OF WORKERS' COMPENSATIONEXHIBIT D-1-c SOLE PROPRIETORSHIP
INFORMATION FORM
To be used in response to Item D-1-c of Form WCHCPO 1.
3. Names of persons performing principal management functions: List each person who occupies a principal management position or who performs principal management functions for the applicant. If this is an amended exhibit, place an asterisk (*) before the names of persons for whom a change in title or duties is being reported and place a double asterisk (**) before the names of persons which are being added to those furnished in the most recent previous filing of this exhibit.
Full Name Last First Middle | Beginning Date Mo. Year | Title and Duties |
STATE OF CALIFORNIA
DIVISION OF WORKERS' COMPENSATIONEXHIBIT D-1-d INFORMATION FORM FOR MISCELLANEOUS TYPES OF ENTITIES.
To be used in response to Item D-1-d of Form WCHCPO 1.
2. State of Organization
3. Date of Organization
5. Names of Principal Officers and Beneficial Owners: List below the names of (a) each person who is a principal officer or trustee of the applicant or who performs principal management functions, and (b) each person who owns of record or beneficially over 5 percent of any class of equity security of the applicant. If this is an amended exhibit, place an asterisk (*) before the name of each person for whom a change in title, status or interest is reported, and a double asterisk (**) before the name of persons which are added to those reported in the most recent previous filing.
Full Name Last First | Beginning Date Mo. Year | Class of Equity Security | Percent of Class | Title and Duties | |
Credits
Note: Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.
History
1. New section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only pursuant to Stats. 1997, Ch. 346, Section 5 (Register 98, No. 16).
This database is current through 6/21/24 Register 2024, No. 25.
Cal. Admin. Code tit. 8, § 9771.62, 8 CA ADC § 9771.62
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