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Model Application Template for the State Children’s Health Insurance Program

Effective Date:

October 1, 2009 16 Approval Date: November 19, 2010 2. Member service responses to claims inquiries; 3. Claims certification, investigation, adjudication, and internal appeals process; 4. Processing and distribution of benefit payments to providers; 5. Appropriate and accurate fee administration; 6. Strict financial accounting and reconciliation; 7. Effective management of networks (if applicable); 8. Demonstrated capability to serve Alabama membership; 9. Effective medical, pharmacy and dental management including medical review of claims decisions; 10. Production of claims, contract, and other legal forms as required; 11. Establishment and maintenance of appropriate banking arrangements; 12. Continuous and accurate electronic transmission of all data; 13. Production of reports that capture claim and utilization experience and trends; 14. Other special services as may be requested from time to time 15. Have a network of physicians, dentists, pharmacies, and other providers capable of meeting the demands of the ALL Kids Program. 16. Facilitation of a medical home for each enrollee.

*The exception to the fee-for-service payment system is the method of reimbursement to federally qualified health centers (FQHCs) and rural health clinics (RHCs) based on a prospective payment system (PPS). This is in compliance with section 503 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA). In accordance with this provision of CHIPRA, ALL Kids has elected to adopt the Medicaid PPS Rates effective October 1, 2009. This method of payment will be implemented August 25, 2010 for all qualifying services rendered on or after October 1, 2009.

In the past, ALL Kids has used three (3) insurance venders, Blue Cross Blue Shield of Alabama (statewide), Prime Health (in 10 southwestern counties from 10/98-9/00) and United Healthcare (14 counties from 10/01-7/02) for the above services. However, due to low enrollment in Prime Health and United Healthcare (which was due to patient choice), each of those programs elected, with the mutual consent of the ALL Kids program, to discontinue serving as an ALL Kids vendor. Currently, the only ALL Kids vendor for the above services is Blue Cross Blue Shield of Alabama. This vendor provides services statewide.

CHIP makes health care coverage available to all individuals eligible for ALL Kids on a “guaranteed issue” basis with no exclusions of coverage for pre-existing conditions, and on a “guaranteed renewable” basis for those eligible.

ALL Kids PLUS Program Operation-Administration For this addition to the program, the Alabama Department of Public Health has partnered (and seeks to partner) with other governmental agencies (which serve special needs children) to provide the state match, provide or provide for covered ALL Kids PLUS services, to authorize