Get Application For Certificationre-certification To Perform Utilization Review* - Health Ri 1983-2025

This guide provides clear instructions on completing the Application For Certification/Re-certification To Perform Utilization Review online. Following these steps will help ensure your submission is accurate and compliant with the required guidelines.

Follow the steps to effectively complete your application online.

1. Press the ‘Get Form’ button to access the application form and open it in your editing interface.
2. Begin by filling out the name of the utilization review applicant in the designated field. If applicable, include the name under which the applicant conducts business in Rhode Island.
3. Indicate whether you are submitting an application for new certification or for re-certification. If you are re-certifying, be sure to provide your current certificate number and expiration date.
4. Provide the name and title of the utilization review agency’s President or CEO, and include their mailing address, phone number, fax number, and email address.
5. Fill in the billing contact information, including name, title, mailing address, phone number, fax number, and email address. Ensure that these details are accurate for effective communication.
6. Carefully review and complete the required sections outlined in the application guidelines, which include information pertaining to utilization review, policies and procedures, adverse determination notifications, enrollee information, and external review contracts.
7. Prepare to provide evidence of current utilization review accreditation alongside any correspondence that could impact the agency's accreditation status. Note whether your agency performs utilization review for mental health and substance abuse services.
8. Indicate ownership type for the review agency, selecting the appropriate category: individual, partnership, or corporation.
9. Affirm that all information provided is true and complete by including the signature of the authorized person from the utilization review agency along with their title and date of signature.
10. Ensure that the application is notarized where indicated. The notary public must verify the identity of the person signing the application.
11. Once completed, you can save your changes, download the form for your records, print a copy, or share it with relevant parties as needed.

Complete your application online today to ensure timely processing and compliance.