Rule 52: Managed Care — Application for Certification

A. Application. Any person or entity may make written application for certification by the court of a plan to provide management of quality treatment to injured employees for injuries and diseases compensable under the Nebraska Workers’ Compensation Act. Any such application shall be submitted to the court, together with one identical copy, and shall include the following information.

1. The Application must describe the manner in which the plan will meet the requirements of Rule 51 to Rule 61 and section 48-120.02, including a description of the times, places, and manner of providing health care services under the plan, and a statement describing how the plan will ensure an adequate number of each category of health care providers listed in Rule 53,C is available to give employees convenient geographic accessibility to all categories of health care providers and adequate flexibility to choose the primary treating physician pursuant to Rule 53,E,3.

2. The Application must identify the following (an individual may act in more than one capacity):

a. the names of all directors and officers of the managed care plan;

b. the title and name of the person to be the day-to-day administrator of the managed care plan;

c. the title and name of the person to be the administrator of the financial affairs of the managed care plan;

d. the name and medical specialty, if any, of the medical director; and

e. the name, address, and telephone number of a communication liaison for the court, insurer, risk management pool, employer, and the employee.

3. The Application must provide a copy of any standard contract used with health care providers who will deliver services under the managed care plan, and a description of any other relationships with health care providers who may deliver services to a covered employee, together with a copy of any related contract. The managed care plan must provide a list of names, clinics, addresses, telephone numbers, types of license, certification or registration, and specialties for the health care providers subject to the contracts. The managed care plan must also submit a statement that all licensing, certification or registration requirements for the health care providers are current and in good standing in Nebraska or the state in which the health care provider is practicing.

4. The Application must identify any entity, other than health care providers, with whom the managed care plan has a joint venture or other agreement to perform any of the functions of the managed care plan, together with a description of the specific functions to be performed by each such entity. Copies of the related contracts must also be provided.

5. The Application must disclose to the court the existence of any of the following factors and any equivalent interest the managed care plan has in an insurer, risk management pool or employer. The court may consider these factors and any other relevant information in determining whether a managed care plan shall be certified. If an insurer, risk management pool, or employer, or any member of the staff of such entity:

a. directly participates in the formation or certification of the plan; or

b. occupies a position as a director, or other governing member, officer, agent, or employee of the plan; or

c. has any ownership interest or similar financial or investment interest in the managed care plan; or

d. enters into any contract with the plan that limits the ability of the plan to accept business from any other source; or

e. has any relationship not listed above with a managed care plan, other than a contract for the provision of medical, surgical, and hospital services under the Nebraska Workers’ Compensation Act.

Rule 52,A,5 is not intended to prohibit an insurer, risk management pool, or employer, from forming, owning, or operating a managed care plan, so long as the plan includes adequate safeguards to insure fairness and equity in the operation of the plan and in the provision of medical, surgical, or hospital services under the plan.

6. The Application must include satisfactory evidence of ability to meet the financial requirements necessary to ensure delivery of service in accordance with the plan.

7. The Application must include a copy of the organizational documents of the applicant, such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents, as well as the bylaws or similar document, if any.

8. The Application must identify one place of business in this state where the plan is administered and membership records and other records are kept, or if the plan is located outside the state of Nebraska, the Application must identify one such place of business in such other state and must also include a statement that the plan agrees and stipulates to the jurisdiction of Nebraska courts for all purposes.

B. Fees. Each application for original certification or application for certification following revocation must be accompanied by a nonrefundable fee of $1,500. The fee for the annual report is established in Rule 57.

C. Notification; approval or denial.

1. An application received by the court shall be approved if such application meets all the requirements as set out in Rules 51 through 61. The court may request of the applicant further information or clarification of information submitted pursuant to Rule 52,A,1 through Rule 52,A,8. Failure to respond to a request from the court or failure to meet the requirements shall result in a denial of certification. A letter detailing the reason(s) for denial shall be sent to the applicant within five working days of the decision by the court to deny the application.

2. An applicant denied certification pursuant to Rule 52,C,1 shall be permitted to reapply no earlier than 30 days after receipt of the notice of denial of certification. Such reapplication shall be accompanied by a nonrefundable fee of $750. In no event shall an entity be allowed to reapply for one year after having been denied certification three consecutive times.