ࡱ> JLIq` /bjbjqPqP 48::         (((8`D$ ?" j!l!l!l!l!l!l!$"h]%!i !  !2!2!2!d  j!2!j!2!2!  2! ruO(2!j!"0?"2!& &2!& 2!8BvT2! DPbBBB!! ^BBB?"   d              Managed Behavioral Health Care Organization Initial Report to the New Jersey Department of Banking and Insurance in accordance with P.L. 2005, c. 172 and Bulletin 06-05 Instructions: All carriers offering or having in force health benefits plans are to complete this form, or otherwise provide the requested information, even if the carrier does not own or contract with a managed behavioral health care organization (MBHCO). If a carrier does not own or contract with an MBHCO, indicate none. All terms are as defined at N.J.S.A. 26:2S-2 (as amended by P.L. 2005, c. 172). Completed reports should be submitted to: New Jersey Department of Banking and Insurance Life and Health Actuarial MBHCO Reporting P.O. Box 325 Trenton, NJ 08625-0325 (express mail or private delivery: 20 West State Street) Fax: (609) 633-0527 Please note: the Department may request a report to be mailed if a fax is not legible. 1. Carrier Contact Information (note: contact information should be for the person submitting this information or someone at the carrier familiar with the contents of this report) a. Carrier Name:  FORMTEXT       b. NAIC #:  FORMTEXT       c. Contact Name:  FORMTEXT       d. Contact Title:  FORMTEXT       e. Contact Address: FORMTEXT       f. Contact Telephone #:  FORMTEXT       g. Contact Fax #:  FORMTEXT       h. Contact E-mail address:  FORMTEXT       2. MBHCO Information (note: for purposes of this report, affiliation constitutes ownership) a. MBHCO Name:  FORMTEXT       b. Carrier Ownership interest: Yes  FORMCHECKBOX  No  FORMCHECKBOX  If Yes, describe:  FORMTEXT       c. Contract for services: Yes  FORMCHECKBOX  No  FORMCHECKBOX  If Yes, provide the beginning and ending date of the contract (use the anniversary date as the ending date, if an end date is not otherwise specified): Beginning:  FORMTEXT       ,4;    . 0 2 < > J L p r ⣵↵t↵b↵#jhejhCJUaJ#jthejhCJUaJhEhCJaJ"jhCJUaJmHnHu#jhejhCJUaJjhCJUaJhh5CJaJhejh5CJaJh>*CJaJhCJaJh5CJaJh h5CJaJ&;qo ( > qqqqqq7$ & #$$d%d&d'd/NOPQa$gd7$ & #$$d%d&d'd/NOPQa$gd$ a$gd$ a$gd // @ X xz6>LfX$ gd 6^`6gd ^gd gd$ a$gd 024>@X  PRfhjtvz~ڽڽڽuihejh5CJaJ#j,hQhCJUaJ#jhQhCJUaJ#jDhQhCJUaJ#jhQhCJUaJhEhCJaJ"jhCJUaJmHnHujhCJUaJ#j\hejhCJUaJhCJaJ(bdxz| 8:<z|(*Fֲ|ֲj#jrhQhCJUaJ#jhQhCJUaJ#jhQhCJUaJ#jhQhCJUaJ"jhCJUaJmHnHu#jhQhCJUaJjhCJUaJhCJaJh5CJaJhh5CJaJ"FHJ$0$2$F$H$J$T$V$%%6%8%:%%%%%%%%&&&d&f&&ٳ١ُ}k#j.hQhCJUaJ#jhQhCJUaJ#jFhQhCJUaJ#jhQhCJUaJU"jhCJUaJmHnHu#jZhQhCJUaJhCJaJjhCJUaJ#jhQhCJUaJ$ Ending:  FORMTEXT       If Yes, what services are covered by the contract with the MBHCO:  FORMCHECKBOX  behavioral health  FORMCHECKBOX  claims payment  FORMCHECKBOX  quality assurance  FORMCHECKBOX  provider credentialing  FORMCHECKBOX  utilization management  FORMCHECKBOX  um appeals  FORMCHECKBOX  other (please list):  FORMTEXT       3. X$n$$%&x''4,,,B---b.d.f.h.j.//J/L///// ^gd gd gd&&&&&&&&<'>'Z'\'^'~''''''''''''''(,2,8,Z,\,p,ٵ٣ّsqsfhEhCJaJUhejh5CJaJ"jhCJUaJmHnHu#jv hQhCJUaJ#j hQhCJUaJ#j h+S2hCJUaJ#j hQhCJUaJhCJaJjhCJUaJ#jhQhCJUaJ!MBHCO Contact Information a. Contact Name:  FORMTEXT       b. Contact Title:  FORMTEXT       c. Contact Address: FORMTEXT       d. Contact Telephone #:  FORMTEXT       e. Contact Fax #:  FORMTEXT       f. Contact E-mail address:  FORMTEXT       Signature: ___________________________________ Date:  FORMTEXT       Name (print):  FORMTEXT       Title:  FORMTEXT       cmcd06-01b/inoord     p,r,t,~,,,,,,,,,,,,,-----(-*-D-t-v----------------:.<.P.ļἪļἘἆļtļ#j hQhCJUaJ#jN hQhCJUaJ#j hQhCJUaJ#jb hQhCJUaJhCJaJhEhCJaJ"jhCJUaJmHnHujhCJUaJ#j hQhCJUaJ+P.R.T.^.`......./"/$/8/:/Nz,YEF&3,7{\  A n 1 2 3 4 5 0000000000000000000000000000000000000000000000000000000000000000I00I00I00I00@0@0@0@0@0@0I00;qo(>Nz,YEF&3,7{\  A n 1 2 3 4 5 @0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0$  0t@0@0X@0\@ 00  F&p,P.//  X$// / frx EQWr~1=Ct $$* 2 B l | - 9 ? Z f l  ) / m y  FFFFFFFFFG$G$FG$G$FFG$G$G$G$G$G$G$FFFFFFFFFF!Text1Text2Text3Text4Text5Text6Text7Text8Text9Check1Check2Text10Check3Check4Text11Text12Check5Check8Check6Check9Check7Check11Check10Text13Text14Text15Text16Text17Text18Text19Text20Text21Text22gFs2u3 m . 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