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

Effective Date:

October 1, 2009 35 Approval Date: November 19, 2010 instructed to submit a predetermination request to BCBS. BCBS reviews all provider requests to determine dental necessity of services and ALL Kids provides final approval to pay for services exceeding $1500. Providers regularly utilize this process and payment by exception requests are routinely approved for dental services. Dentally necessary services are provided in a timely manner regardless of the time of year. There is no unnecessary carry-over of services that need immediate attention.

If a family would like to appeal the BCBS/ALL Kids decision regarding the application of “medically necessary,” there is an appeals process which is consistent with the requirements of 42 CFR 457.1160 (b) and in compliance with state laws, the Security Act of 1974 (ERISA) and all other applicable regulations of the Department of Labor Procedures. See attachment E for the Blue Cross and Blue Shield of Alabama Appeals Process.

6.2.1.2-D ~ Periodicity Schedule. The State has adopted the following periodicity schedule:  State-developed Medicaid-specific X American Academy of Pediatric Dentistry  Other Nationally recognized periodicity schedule  Other (description attached)

6.2.2-D ~ Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420)

6.2.2.1.-D ~  FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy of the dental supplemental plan benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, please also attach a description of the services and applicable CDT codes)

6.2.2.2-D ~  State employee coverage; (Section 2103(c)(5)(C)(ii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, please also attach a description of the services and applicable CDT codes)

6.2.2.3.-D ~  HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, please also attach a description of the services and applicable CDT codes)

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1. X The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR