Utilization Review Licensing in Louisiana

Independent Review Application

$500

• Copy of the Articles of Incorporation, Articles of Association, partnership agreement or other such organizational documents and all amendments thereto of the applicant certified by the proper domiciliary official. The certification must be dated within 90 days of submission.
• Copy of the by-laws, operating agreement, rules, regulations or similar document of the applicant certified as true and correct by the secretary of the applicant. The certification must be dated within 90 days of submission.
• Trade name certificate issued by the Secretary of State of Louisiana confirming registration of any trade name with that Office. This item must be supplied by any applicant utilizing a trade name in Louisiana.
• Completed biographical affidavits for all persons responsible for the conduct of affairs of the applicant. This should include all officers, all directors, all partners (in the case of a partnership), all trustees, all executive committee members and all person(s) owning, directly or indirectly, 10 percent or more of the applicant and any other person who exercises control or influence over the affairs of the applicant.
• Copy of the procedures manual of the applicant which meets the statutory requirements for making performing external independent reviews. Required only from applicants which are not accredited by URAC.
• A detailed description of the corporate organizational/ownership structure of the applicant, its parent company and all affiliates. This description should include a chart showing the ownership percentages for any persons owning 10 percent or more of the applicant and all affiliated entities up to and including the ultimate controlling person. The chart must include the state of domicile and the Federal Employer Identification Number (FEIN) for each person.

Utilization Review Organization (URO) Application

$1,500

• A copy of the articles of incorporation, articles of association, partnership agreement or other such organizational documents and all amendments thereto of the applicant certified by the proper domiciliary official. The certification must be original and dated within 90 days of submission.
• A copy of the bylaws of the applicant certified as true and correct by the secretary of the applicant, if a corporation; a partner, if a partnership; or other appropriate person. This certification must be within 90 days of submission.
• A copy of the trade name certificate issued to the applicant by the Louisiana Secretary of State. This item must be supplied by any applicant utilizing a trade name or d/b/a in Louisiana.
• Completed biographical affidavits for all persons responsible for the conduct of affairs of the applicant. This should include all officers, all directors, all partners (in the case of a partnership), all trustees, all executive committee members and all person(s) owning, directly or indirectly, 10 percent or more of the applicant and any other person who exercises control or influence over the affairs of the applicant. This must include a completed affidavit for the medical director of the applicant.
• A copy of the applicant’s procedure manual which meets the requirements of Chapter 18 of the Louisiana Insurance Code (La. R.S. 22:2391-2453) for making clinical or medical necessity determinations and resolving disputes in the internal claims and appeals process.
• A description of procedures used in making adverse determinations that describes all review activities performed for health benefit plans in Louisiana.
• Samples of the forms of all contracts with health insurance issuers in use or to be used by the applicant. These forms should not include fees charged.
• A general description of operation of the applicant, which includes a statement that the applicant does not engage in the practice of medicine or act to impinge or encumber the independent medical judgment of treating physicians or health care providers.
• A completed Statement of Compliance for the forms and procedures submitted with this application.
• A detailed description of the corporate organizational structure of the applicant, its parent company and all affiliates. This description should include a chart showing the ownership percentages for any persons owning 10% or more of all affiliated entities up to and including the ultimate controlling person.