Managed care organization (MCO) certification process
Eligibility for MCO certification
Any health care provider or group of medical service providers may apply to the Department of Consumer and Business Services (DCBS) director to become a certified MCO. Oregon law prohibits an organization that is formed, owned, or operated by an insurer or employer other than a health care provider to be certified as an MCO. This ensures an arm's length relationship between the providers of medical services and insurers to avoid the company doctor syndrome, thereby striking a balance between quality care and cost-effective care.
Certification – a two-part process
Notice of Intent to form a managed care organization
The Notice of Intent is designed to protect interested parties from committing antitrust violations when they are meeting to discuss formation.
Proposed plan of operation
The plan shows how the MCO applicant intends to comply with the certification requirements of OAR 436-015-0030, including access to medical providers within a reasonable distance from the workers' places of employment; how workers will be informed of such providers; how attending physicians will be identified; how workers will receive specialized medical services that the MCO does not provide; and how the MCO will obtain, develop, and update treatment standards so workers will receive timely, effective, and convenient care. The plan must also provide procedures for utilization review, peer review, and dispute resolution.
The application for certification must be submitted to the department with a nonrefundable fee of $1,500. The application includes the names and addresses of medical providers contracting with the MCO. This information is used to ensure that workers have adequate access to medical providers of different specialties. The application identifies the geographic service area (GSA) in which the MCO proposes to operate. Application materials must include an organizational chart and identify the individuals who will serve as directors, president, day-to-day administrator, and the administrator of the MCO's financial affairs. The applicant must also provide the name of the individual who will serve as communications liaison to DCBS and insurers contracting with the MCO.
Within 45 days of receipt of all required information, DCBS will notify the applicant of the effective date of certification and authorized GSAs. If denied, the applicant is given the reasons for denial. Subsequent amendments to the certified plan must be filed with DCBS, and the MCO is not authorized to act pursuant to any such amendment until DCBS approves the amended plan.
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