Valuation Bureau Applications

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Valuation Bureau Applications

Mail or fax requests for Health Maintenance Organization (HMO), Selective Contracting Arrangement (SCA), Workers' Compensation Managed Care Organization (WCMCO), Dental Plan Organization (DPO), Dental Service Corporation (DSC) or Organized Delivery Systems (ODS) application packets to the attention of the bureau secretary. The packets contain application forms, item checklists, and relevant New Jersey statutes and regulations.

Address questions regarding applications to a Bureau Health Care Consultant specializing in that area.

Health Maintenance Organization (HMO)

HMO Application

Medicare Only Application - MS Word or PDF

or
All Other HMO Application - MS Word or PDF
- Attachments:
  - Physicians by Region - North (PDF)
  - Physicians by Region - Central (PDF)
  - Physicians by Region - South (PDF)
  - Summary of Physicians by County (PDF)
  - General Acute Care Hospitals (PDF)
  - Summary of Ancillary, Tertiary and Specialized Providers by County (PDF)
  - Capital and Surplus Guaranty (PDF)
  - Provider Agreement Certification (Fillable MS Word - Download document and type or select your answers, where applicable; print out completed form; affix the appropriate signatures)

2021 HMO Annual Supplement Forms
- Commercial (MS Excel)
- Medicaid (MS Excel)
- Surrender of HMO Certificate of Authority (PDF)

Selective Contracting Arrangement (SCA)

SCA Application (PDF)
Attachments:
- General Acute Care Hospitals (PDF)
- Ancillary and Specialized Providers by County (PDF)
- Dental Providers Only (PDF)
- Vision Providers Only (PDF)
- Summary of Physicians by County (PDF)
- Physicians by Region - North (PDF)
- Physicians by Region - Central (PDF)
- Physicians by Region - South (PDF)
- Provider Agreement Certification (Fillable MS Word - Download document and type or select your answers, where applicable; print out completed form; affix the appropriate signatures)
SCA Annual Report (MS Excel)

Workers' Compensation Managed Care Organization (WCMCO)

WCMCO Application (PDF)
Attachments:
- Ambulatory Site Contacts (PDF)
- General Acute Care Hospitals (PDF)
- Summary of Ancillary, Tertiary and Specialized Providers by County (PDF)
- Summary of Physicians by County (PDF)
WCMCO Annual Report (PDF)
WCMCO Annual Financial Filing (PDF)
WCMCO Regulation: NJAC 11:6-2.1 et seq. - See Statutes and Regulations

Dental Plan Organization (DPO)

DPO Application (Application is currently under revision; contact for more information)
DPO Annual Report Supplement Form (PDF)
DPO Quarterly Report Supplement Form (PDF)
List of Statutes and Regulations for DPOs (PDF)
Name Change Instructions (PDF)

Dental Service Corporation (DSC)

Organized Delivery System (ODS)

Application for certification (PDF)
Attachments:

Summary of Physicians by County (PDF)
Physicians by Region - North (PDF)
Physicians by Region - Central (PDF)
Physicians by Region - South (PDF)
General Acute Care Hospitals (PDF)
Summary of Ancillary, Tertiary and Specialized Providers by County (PDF)
Dental Providers Only (PDF)
Vision Providers Only (PDF)
Provider Agreement Certification (Fillable MS Word - Download document and type or select your answers, where applicable; print out completed form; affix the appropriate signatures)

Application for licensing (PDF)
Certified Organized Delivery System (CODS) Annual Report

Biographical Affidavit

Biographical Affidavit



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