Product Regulation Ohio Department of Insurance Life & Health, Managed Care rdJohn R. Kasich – Governor 50 W. Town St., 3 Fl Mary Taylor – Lt. Governor/Director Suite 300 Columbus, OH 43215 (614) 644-2661 Application for Accreditation as an IRO for Fax # (614) 728-5238 Entities with National Accreditation www.insurance.ohio.gov
Application for accreditation as an Independent Review Organization for Entities Accredited by a National
Organization/Certification of Compliance with Ohio Specific Requirements
To be submitted along with proof of current accreditation by a national organization that accredits
independent review organizations. Proof shall include a certificate or letter of accreditation.
Legal Name of Applicant Federal Tax Identification Number Type of Entity: Corporation Partner Association Limited Liability Company Other Contact Person Name Phone Number Title ( ) Business Address Street (do not use P.O. Box) City State Zip Mailing Address Street (if different from business address) City State Zip Phone Number Fax Number Email Address State of Incorporation ( ) ( ) List all other states in which Applicant is approved to conduct external reviews. Identify all accreditations held by the Applicant. Has the Applicant ever been refused approval or accreditation to perform independent reviews? Yes No If yes, please explain. Has the Applicant ever lost approval or accreditation to perform independent reviews? Yes No If yes, please explain.
1. Provide a chart showing the internal structure of the Applicant’s management and administrative staff. 2. Provide a list and brief description of all contractual arrangements between the Applicant, its parent, or any affiliates or subsidiaries. 3. Provide a list and brief description of all contractual arrangements that relate to the Applicant’s operations as an independent review organization. Note: Independent review organizations cannot subcontract services performed on behalf of Ohio Residents to another entity. 4. Provide an organizational chart of the holding company system that includes all of the information listed below for each entity that controls [as defined in Ohio Revised Code Section 3901.32(B)] or is controlled by the Applicant and all affiliates: a. The full legal name of the corporation or organization, b. Its state of incorporation or organization, c. A description of the goods and services it produces or provides, d. The nature and extent of the affiliation or control. Note: The holding company system includes any and all affiliates of the Applicant. 5. Include a list of any currently outstanding loans between the Applicant and any affiliates.
Accredited by the National Association of Insurance Commissioners (NAIC) INS5035 (Rev. 01/2011) Page 1 of 5
Ohio Department of Insurance Application for Accreditation as an IRO for Entities with National Accreditation
1. Provide a copy, certified by the Secretary of State, of the Applicant’s Articles of Incorporation or Articles of Organization and all amendments to the documents. 2. Provide a copy, certified by a company officer, of the Applicant’s bylaws and all amendments. 3. Provide a certificate of good standing from your state of incorporation (corporations only). 4. Is the Applicant a publicly held entity? Yes No 5. Are there any stockholders or owners of more than 5% of any stock or options? Yes No If yes, give the name, address, percent of ownership, and Federal Tax Identification Number of each stockholder or owner of more than 5% of any stock or options.
1. Is the Applicant a general partnership or limited partnership? 2. Provide a complete list of all partners, including full name, address, percent of ownership and Federal Tax Identification Number. 3. Provide a true and complete copy of your organizational documents including whatever is required by the state of domicile, the organization’s partnership agreement, and all amendments to the documents.
Provide a certified copy of organizational documents appropriate to the Applicant. The organizational documents must include: any documents the state of domicile requires to be filed before the entity is authorized to operate in said state; the organization’s bylaws; and all amendments to the documents.
Provide a listing giving the amount of bond or note for any holder of bonds or notes of the Applicant that exceeds $100,000 and for entities and individuals, their name, address, and Federal Tax Identification Number.
1. Include the name and a complete biographical affidavit and release for each director or trustee, and officer of the Applicant, using the Department’s forms. 2. Include the name and a complete biographical affidavit and release for each similar person of any entity that owns or controls more than 5% of the Applicant. 3. In addition to the name and complete biographical affidavit and release, include for each individual a description of any professional, familial, or financial affiliation the named individual has with each of the following: a. A health insuring corporation or health maintenance organization, b. An insurer, c. A public employee benefit plan, d. A third party payor, e. A health care provider, f. A group representing any of the entities listed in items (a) through (e), g. Anyone employed by the Ohio Department of Insurance.
Is the Applicant an entity which is domiciled in the state of Ohio? Yes No If yes, provide a certified copy of the Agent for Service of Process form as filed with the Ohio Secretary of State’s Office. If no, the Applicant must apply with the Ohio Secretary of State’s Office to conduct business in Ohio as a foreign entity. Pl