Office of Managed Care Regulation

Health Plan and Utilization Review Agency Application & Reporting Forms

Application for Certification

All entities that maintain a network of providers in RI and/or offer financial incentives to enrollees to use such networks require Health Plan (HP) certification.  All Utilization Review (UR) agencies conducting UR for RI residents and/or services rendered in RI require UR certification.  Certification/re-certification applications are reviewed for document and operational compliance. Re-certification is required biennially. 

To apply as an HP, refer to the requirements within the Health Plan Application Guidelines

• Application for Health Plan Certification/Re-certification
• Application for Health Plan Certification/Re-certification Assurances
• Mandatory Addendum to License Application

To apply as a UR agency, refer to the requirements within the UR Application Guidelines

• Application for Certification/Re-certification to Perform Utilization Review 
• Application for Utilization review Agencies Assurances
• Mandatory Addendum to License Application

Consumer Disclosure Documents

If applicable, please refer to the Instructions for Consumer Documents   for submission to and approval from the Department. Health plans must follow the standardized format, Consumer's Right to Know About Health Plans in Rhode Island .

Also, please refer to: Consumer's Information about Health Plans in Rhode Island

Reporting

As part of the certification requirements, quarterly statistical reports are also required of HPs and UR agencies.  Annual statistical reports are required of HPs with 10,000 or more Rhode Island enrollees.

• Health Plans

Health Plan Data Reporting Form (Quarterly Report for Health Plans with Total Rhode Island Enrollment of More than 5,000)

Health Plan Data Reporting Form (Annual Report for Health Plans with Total Rhode Island Enrollment of Less than 5,000)

For HPs with more than 10,000 Rhode Island enrollees, please contact Bruce Cryan of the Office of Performance Measurement and Reporting at 401-222-5123.

• Utilization Review

Utilization Review Quarterly Reporting Form

Once completed, forms may be sent to:

Rhode Island Department of Health
Office of Managed Care Regulation
3 Capitol Hill, Room 410
Providence, RI 02908-5097
 Phone:  (401) 222-6015
Fax:  (401) 222-3017