Health Service Fee Database Certification Application {WKC-9351}

WKC-9351 (N. 05/2014) 1 HEALTH SERVICE FEE DATABASE CERTIFICATION APPLICATION Use this form to obtain certification of your health service fees database as required by s.102.16(2), Wisconsin Statutes. Answer each question. If more space is needed, use additional pages (identify your response with the question number.) If you have any questions about any item requested, please call (608) 261-8474. A. ORGANIZATION INFORMATION 1. Organization Name Organization Address 226 Street, P.O. Box, City, State, Zip Code 2. Contact Person 226 Name and Title Telephone Number ( )- 3. How many years has your organization been in business? How many years in business in Wisconsin? 4. Identify the primary customers of your organization222s database: 1. 2. 3. 4. 5. 5. List five (5) customers as references (Provide customer name, address and telephone number): 1. ( ) 2. ( ) 3. ( ) 4. ( ) 5. ( ) Department of Workforce Development Worker222s Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Imaging Server Fax: (608) 260-2503 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://dwd.wisconsin.gov/wc e-mail: DWDDWC@dwd.wisconsin.gov American LegalNet, Inc. www.FormsWorkFlow.com WKC-9351 (N. 05/2014) 2A. ORGANIZATION INFORMATION 6. What services relating to medical treatment and medical fees does your organization provide? 1. 2. 3. 4. 5. 7. Who are the primary owners of your organization (such as trade association, insurer or noninsurer)? 1. 2. 3. 4. 5. 8. List the states in which your organization is doing business: 1. 2. 3. 4. 5. 9. Is there any pending litigation, relating to your database, in which your organization is involved? Yes No If yes, explain the circumstances: American LegalNet, Inc. www.FormsWorkFlow.com WKC-9351 (N. 05/2014) 3B. DATABASE INFORMATION 1. Before the department may certify a database, it must determine that all of the following are met. Explain how your database meets EACH requirement. Use additional pages as needed and please identify your response with the question number and letter. a. The fees in the database accurately reflect the amounts charged by providers for procedures rather than the amounts paid to or collected by providers and do not include any Medicare charges. b. The information in the database is compiled and sorted by CPT code, ICD-9-CM code, ADA code, DRG code or other similar coding accepted by the department. c. The information in the database is compiled and sorted into economically similar regions within the state, with the fee based on the location at which the service was provided. d. The information in the database can be presented in a way, which clearly indicates the formula amount for each procedure. e. The applicant authorizes and assists the department to audit or investigate the accuracy of any statements made in the application for certification by any reasonable method including, if the applicant did not collect or compile the data itself, providing a means for the department to audit or investigate the process used by the person who collected or compiled the data. f. The information in the database is updated and published or distributed by other methods at least every six months. American LegalNet, Inc. www.FormsWorkFlow.com WKC-9351 (N. 05/2014) 4B. DATABASE INFORMATION 2. Before the department may certify a database, it shall consider all of the following. Provide your database response to EACH factor. Use additional pages as needed and please identify your response with the question number and letter. a. The coverage of the database, including the number of CPT codes, ICD-9-CM codes or DRG222s for which there are data; the number of data entries for each code or DRG; the number of different providers contributing Wisconsin service charges to a code or DRG entry and the extent to which reliable data exist for injuries most commonly associated with Worker222s compensation claims. b. The sources from which the data are collected, including the number of different providers, insurers or self-insurers. c. The age of the data and the frequency of the updates in the data. d. The method by which the data are compiled, including the method by which mistakes in charges are identified and corrected prior to entry, the extent in which this occurs, the conditions under which charges reported to the applicant may be excluded, and the extent to which this occurs. e. The extent to which the data are representative of the entire geographic area and specific economically similar regions for which certification is sought. f. The length of time the applicant has been in business and doing business in Wisconsin. g. The length of time the database has been in existence. h. Has the database been certified by any organization or government agency? Yes No If yes, explain below: American LegalNet, Inc. www.FormsWorkFlow.com WKC-9351 (N. 05/2014) 5B. DATABASE INFORMATION 3. Was your database created based on a data collection and storage process plan? Yes No If yes, explain the plan: 4. Does your database have any technical advisers? Yes No If yes, list them and describe their qualifications: Technical Advisor Name Qualifications 5. Name of person primarily responsible for the collection, maintenance and updating of the data in your database? Explain the person222s qualifications: 6. What do you provide if the database does not have adequate data to provide statistically valid information on a particular fee? 7. In what format (such as paper, computer disc or tape) is the data available to clients? How much do you charge your customers for the data? 8. Identify any information your organization considers a trade secret under s. 19.36(5), Wis. Stats. 9. With this application, provide copies of the following: Documents or forms your organization uses to collect data (see Question B6) Audited financial reports for your organization for the last three (3) years All written materials your organization provides to prospective customers concerning the database American LegalNet, Inc. www.FormsWorkFlow.com WKC-9351 (N. 05/2014) 610. Does the applicant conduct audits to its data? Yes No If yes, what type of audits: Internal External Company Name: 11. When was the last time an audit was conducted to the applicant's data? 12. Does the applicant agree to provide the results of the auditing performed to the data if requested by the Department? Yes No If no, explain below: C. AUTHORIZATION The applicant, by its authorized corporate officer: Authorizes the department to audit or investigate the accuracy of any statement made in this application and related documents Agrees to assist the department in conducting the audit or investigation Will allow the department accesses to its business location and to relevant information and records The applicant understands and agrees that if it has misrepresented a material fact in this application or related documents or if it no longer meets the requirements in Ind. 80.72(7) of the Wisconsin Administrative Code, the department may decertify a database or refuse to recertify a database. Applicant Name Applicant Signature Date signed American LegalNet, Inc. www.FormsWorkFlow.com WKC-9351 (N. 05/2014) 7 WORKER222S COMPENSATION DIVISION CERTIFIED DATABASE QUESTIONNAIRE 1. Do you permit any provider reimbursement data to be entered on your system which does not reflect the amount charged, such as PPO discounted charge amounts? Yes No 2. Do you edit, purge or eliminate charge data supplied to you that appears unreasonable? Yes No If yes, please explain the circumstances and the frequency with which charge data is purged or modified. 3. How many providers within your database222s regional units supplied data for your certified Wisconsin database in the latest update supplied to your customers? Please attach a list of each area, the number of medical doctors, and the number of 223Other224 health care providers. Example: Region Milwaukee Medical Doctors 177 Other Providers 105 4. What percentage of your CPT codes has the following frequencies of observations for the entire state of Wisconsin? Office Visits/Medical Surgical Radiology 0 1 - 10 11 - 25 26 226 50 50+