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MANAGED CARE ACCREDITATION AND REACCREDIATION FINAL BLANK APPLICATION 10182018 0

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MANAGED CARE
INITIAL ACCREDITATION AND
RENEWAL (RE-ACCREDITATION)
APPLICATION AND INSTRUCTIONS
UNDER M.G.L. c. 176O
Application
The application contains [4] sections to be completed if your organization is applying
for
Mana
ged Car
e initial accreditation and/or renewal (re-accreditation). All fields on
the application must be completed and all applicable supporting materials must be
submitted to the Division of Insurance (“Division”) by Carriers using the System for
Electronic Rates & Forms Filings (“SERFF”) https://login.serff.com/serff/signin.do
prior to the review *of the application to begin by the Division.
If your organization does not have access to SERFF, please contact the Bureau of
Managed Care (617) 521-7347 to receive information on alternative methods for
submissions.
If your organization requires approval of new product/plans or product/plans not
previously placed on file via SERFF by the Division, please review Compliance
Checklist - Managed Care and additional submission requirements
https://www.mass.gov/lists/compliance-checklists-and-filing-
guidance#compliance-checklists---managed-care-
Section 1: Carrier Contact Information:
Carrier to complete the below information related to the point of contact.
Carrier Name _____________________________________
NAIC #: _____________________________________
Contact Name _____________________________________
Title: _____________________________________
Carrier Mailing Address: _____________________________________
Contact Telephone Number: _____________________________________
Application Type:
______Initial Accreditation ______Renewal (re-accreditation)
Section 2: Carrier Plan Information:
Carrier to complete the below information related to the Products that are new, currently offered
or are being renewed in the market to existing enrolled members but not sold to new members
during the renewal (re-accreditation) effective year.
Product Type
Product Name*
Form #
(if available)
SERFF filing #
associated with
the Product
____HMO ____PPO
____Dual Certificate
____EPO
Example:
Network X
12345678 ABC-12345678
____
New*
____
____Renew only***
____HMO ____PPO
____Dual Certificate
____EPO
____Currently offered
____Renew only
____HMO ____PPO
____Dual Certificate
____
EPO
____Currently offered
____Renew only
____HMO ____PPO
____Dual Certificate
____
EPO
____Currently offered
____Renew only
____HMO ____PPO
____Dual Certificate
____EPO
____Currently offered
____Renew only
____HMO
____
PPO
____Dual Certificate
____EPO
____
____Currently offered
____Renew only
____HMO
____
PPO
____Dual Certificate
____EPO
____
____Currently offered
____Renew only
____HMO ____PPO
____Dual Certificate
____EPO
____Currently offered
____Renew only
____HMO ____PPO
____Dual Certificate
____EPO
____Currently offered
____Renew only
____HMO ____PPO
____Dual Certificate
____EPO
____Currently offered
____Renew only
____HMO ____PPO
____Dual Certificate
____
EPO
____Currently offered
____Renew only
____HMO ____PPO
____Dual Certificate
____
EPO
____Currently offered
____Renew only
*The Product name shall be the marketing name of what is available. Do not provide the plans or
variances.
**New = A product that is not currently being offered but will be in the future.
***Currently Offered = A product that is currently being offered for Consumers to purchase.
****Renew Only = A product that is only available for renewal to those members that are
already enrolled but is not available for new Consumers to purchase.
Section 3: General Instructions and Filing Fees
1. Carrier to complete the application (In section 4 of this document) for the applicable
accreditation.
•
Initial Accreditation – The Organization has not previously received
Managed Care accreditation from the Division
.
•
Renewal (re-accreditation) –
The Organization has previously received
Managed Care accreditation from the Division and needs to renew.
2. Each section of the application must be completed and filed via SERFF with all
applicable supporting
documentation in order for the Division to start the review of the
SERFF filing.
3. A Carrier is requested to upload the completed application and all applicable supporting
documentation in SERFF.
a. If the application is for an initial accreditation, Carrier must select the
“Forms/ Managed Care Initial Accreditation" filing type in SERFF,
then proceed to uploading all applicable materials under the
"Supporting Documentation" tab for each the requirement.
b. If the application is for a renewal (reaccreditation) accreditation,
Carrier must select the "Form/Managed Care Renewal (re-
accreditation) accreditation" filing type in SERFF, then proceed to
uploading all applicable materials under the "Supporting
Documentation" tab for each requirement.
4. A Carrier is requested to file via SERFF the red-line (tracked changes) document
showing changes since
the previous submission to the Division, and the final (clean
copy).
a. If the Carrier does not provide a red-line (tracked changes) document AND
a final (clean copy), the page # and section # columns on the application
and each applicable checklist(s) for each applicable requirement must be
completed
and uploaded in SERFF.
b. If the Carrier does provide a red-line document of the changes AND a final
(clean copy), the Carrier does not need to complete the page # and section
#
column on the application and do not need to complete applicable
checklist(s) for a requirement. All other sections of the application must be
completed (as applicable).
5.
A Carrier is requested to submit all materials as defined in the application and the
regulations
211.CMR.52 https://www.mass.gov/files/documents/2017/10/20/211cmr52.pdf for
initial accreditation and renewal
(reaccreditation) unless otherwise noted in this
document or in SERFF for
both the primary Carrier and all delegated vendors
(who
perform any of the applicable services such
as Utilization
Management, Credentialing,
Behavioral Health, etc.) before the Division begins its review
and/or before
accreditation and/or renewal (reaccreditation) is granted. *Carriers shall not submit the
Provider Directories via SERFF, the Provider Directories must be sent to the Division
on a CD or USB.
6. The filing fee of $1,000 for initial accreditation and/or renewal (re-accreditation) is
required and payable to the Commonwealth of Massachusetts (address is listed in #6
below). *Do not pay fee through SERFF
a. Carriers are required to forward a check or money order to the following
address
within there (3) business days of the submission of application and
supporting
materials in SERFF.
Commonwealth of Massachusetts Division of Insurance
Attn: Bureau of Managed Care
1000 Washington St., Ste. 810
Boston, MA 02118
Section 4: Application
Carrier may refer to each requirement below pertaining to the 211.CMR.52
REGULATION https://www.mass.gov/files/documents/2017/10/20/211cmr52.pdf
relevant to initial
accreditation and reaccreditation. The regulation explains in detail what must be filed.
Initial Accreditation
Required/Regulation
section?
Renewal
Accreditation
Required/Regulation
section?
Requirement Carrier to submit
Materials via
SERFF?
Yes
211.CMR.52.05
(3) (a)
Yes
211.CMR.52.05
(4) (a)
Filing Fee $1,000.00 No, Carrier must
forwarded payment
to the
Division’s office.
Yes
211.CMR.52.05
(3) (b)
No
Utilization Review policies and
procedures
__Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Yes
211.CMR.52.05
(3) (c)
Yes
211.CMR.52.05
(4) (b)
Attestation Utilization review program __Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Yes
211.CMR.52.05
(3) (d)
Yes
211.CMR.52.05
(4) (c)
Annual Survey __Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Yes
211.CMR.52.05
(3) (e)
No
Internal Grievance procedures __Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Yes
211.CMR.52.05
(3) (f)
No
Process to establish guidelines for
Medical Necessity
__Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Yes
211.CMR.52.05
(3) (g)
No
Quality management and improvement
policies and procedures
__Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Yes
211.CMR.52.05
(3) (h)
No
Credentialing policies and procedures for
all Participating Providers
__Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Yes
211.CMR.52.05
(3) (i)
No
Policies and procedures for providing or
arranging for the provision of Preventive
Health Services
__Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Section 4: Application Continued
Initial Accreditation
Required/Regulation
section?
Renewal
Accreditation
Required/Regulation
section?
Requirement Carrier to submit
Materials via
SERFF?
Yes
211.CMR.52.05
(3) (j)
Yes
211.CMR.52.05
(4) (d)
Provider Contracts
(Boilerplates) – Non Risks
__Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Yes
211.CMR.52.05
(3) (l)
Yes
211.CMR.52.05
(4) (f)
Provider Contracts (Boilerplate
Regional, Tiered and Limited
Networks)
__Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Yes
211.CMR.52.05
(3) (k)
Yes
211.CMR.52.05
(4) (e)
Provider Contracts
(Boilerplates) – with
Risks
__Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Yes
211.CMR.52.05
(3) (m)
Yes
211.CMR.52.05
(4) (g)
Network adequacy standards __Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Yes
211.CMR.52.05
(3) (n)
Yes
211.CMR.52.05
(4) (i)
Provider directory No, Carrier must
forward via CD/ USB
to the
Division’s office
Yes
211.CMR.52.05
(3) (o)
Yes
211.CMR.52.05
(4) (h)
Evidence of Coverage __Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Yes
211.CMR.52.05
(3) (p)
No
Disclosure described in 211 CMR
52.14
__Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Yes
211.CMR.52.05
(3) (q)
Yes
211.CMR.52.05
(4) (k)
Attestation compliance with 211
CMR 52.16
__Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
No Yes
211.CMR.52.05
(4) (j)
Material Changes to any of the
information contained in 211 CMR
52.05(3)(b), (e), (f), (g), (h), (i), and
(p)
__Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Yes
211.CMR.52.05
(3)
Yes
211.CMR.52.05
(4)
Deemed Accreditation materials __Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
Yes
211.CMR.52.05
(3) (r)
Yes
211.CMR.52.05
(4) (i)
Other as required by the Division’s
Commissioner
__Yes __No
If Carrier will not provide materials via SERFF, please provide justification here:
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Completed 15 November 2019

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