(1) An applicant must submit information in the preliminary application that describes the organizational structure of the MCO and discloses information about individuals and entities that have an ownership or management interest in the MCO.

(2) An applicant must provide the following information:

(a) the complete name of the MCO;

(b) all fictitious business names which the MCO will use;

(c) the type of organizational entity (e.g. corporation, partnership, joint venture, limited liability company) used by the MCO, supported by documentation from the Montana secretary of state showing that the entity is qualified to do business in Montana and is in good standing;

(d) the street and mailing address of the principal Montana office of the MCO;

(e) an organization chart that depicts the primary departments or functions of the MCO;

(f) the names and occupations of all directors and officers, by whatever title, of the MCO; and

(g) a signed statement from the day-to-day administrator of the MCO certifying that the MCO is not formed, owned or operated by a workers' compensation insurer or self-insured employer, other than a health care provider.

(3) An applicant must disclose the existence of any of the following relationships and provide such information concerning the relationship(s) as the department may reasonably request:

(a) common ownership by or with any other business entity;

(b) common management with any other business entity;

(c) management or ownership by any person or entity that was or currently is associated with a MCO or MCO applicant; or

(d) the name of any entity, other than individual health care providers, with whom the MCO has a joint venture or other agreement to perform any of the functions of the plan, and a description of the specific functions to be performed by each entity.