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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998

Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/04, 8/11/05, 10/1/06, 7/1/09, 7/1/10, 7/1/11, 7/1/12 40 HEDIS, CAHPS and other standards. Plans not meeting performance standards established by FHKC are then engaged in Performance Improvement Projects (PIPs) which are also monitored by ICHP. Additionally, FHKC has contracted with an independent medical quality auditor, also currently ICHP, who will review medical records as well as conduct site visits on a random sample of providers and assess appointment and network accessibility. The auditor’s reports will be presented to a designated committee of the FHKC Board of Directors for any necessary action. Plans are reviewed annually for compliance with FHKC’s appointment, access and credentialing standards. Children’s Medical Services Network The CMSN uses the same utilization controls employed by the Healthy Kids Corporation. In addition, CMSN uses teams of health care professionals to determine the medical necessity for certain services such as private duty nursing and skilled nursing facilities. Providers are expected to have internal and concurrent utilization management programs. In addition, CMSN is subjected to Medicaid’s peer review organization and other Medicaid reviews for Medicaid children with special health care needs. For specialized behavioral health benefits for SED children, the Department of Children and Families will use the same utilization controls that are currently in place to manage Medicaid mental health service utilization. Certain services (such as psychiatric hospitalization) will require pre-authorization. Other services will be reviewed on a selected basis for under- or over-utilization.

Claims Payment The Children’s Medical Services Network and MediKids comply with the provisions of 42 CFR 447.45 related to timely claims payment for its Title XXI population.