Sec. 10.09.57.02. Application for Qualification as a Partially Capitated Provider

A. An applicant shall demonstrate to the satisfaction of the Department that it has the managerial, financial, clinical, and administrative capability to carry out the duties required by these regulations.

B. An applicant shall submit the following documents to the Department along with a completed application form:

(1) A narrative of the applicant's overall plan for providing and arranging for the provision of high quality services to enrollees efficiently, effectively, and economically;

(2) A description of the organization and staff responsible for delivering health care and a copy of the applicant's organizational documents;

(3) An annualized pro forma budget and financial plan for the operation of the organization or, at the Department's option, of the appropriate unit within the organization responsible for the operation for delivery of services pursuant to this regulation for the first 3 years of its anticipated operations which demonstrates its financial viability based on reasonable assumptions;

(4) An annualized cash flow chart;

(5) A statement of policy and procedures for accounting, methods of reimbursing subcontractors, and payment of emergency and out-of-area claims;

(6) Balance sheets;

(7) Any other financial information the Program requires;

(8) Full and complete information at all times as to the identity of each person or corporation with an ownership or control interest in the PCP and of any subcontractor in which the applicant has a 5 percent or more ownership interest;

(9) A detailed description of the applicant's quality assurance plan which demonstrates compliance with Regulation .07 of this chapter;

(10) A description of a system for the receipt and prompt adjudication of complaints and grievances by enrollees which complies with Regulation .12 of this chapter;

(11) A description of the process by which data about services provided will be collected;

(12) Copies of all of the applicant's contracts with subcontractors;

(13) A description of the boundaries of the geographic area or area the applicant wishes to serve; and

(14) A copy of the applicant's marketing plan.

C. If the applicant will be at risk for services it will not directly provide, the applicant shall identify and document a source of funds which will comprise the reserve account required by Regulation .10 of this chapter.