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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 93 the designation of hospital facilities in the network. • Physician Credentialing Standards: CMSN maintains physician-credentialing standards that exceed the standards of the National Committee for Quality Assurance. Specifically, primary care physicians in the CMSN must meet the following criteria:  Pediatrician or Family Practitioner with Board Certification; or  Non-board certified physician applicants who meet requirements for board certification examination might be approved for active status pending completion of board certification. The physician must achieve board certification before their re-approval date. There is a standard waiver process to grant exceptions to the standard under special circumstances and when in the best interests of the CMSN participants. Examples of these exceptions include: rural areas that are unable to meet the access standards without including other health care providers in the network, physicians serving inner city areas, physicians that have been practicing medicine for an exceptional length of time and physicians that are currently serving the required years of practice before taking the examination for board certification. Physicians that require an exemption are reviewed on an individual basis by CMSN health care staff, the local CMS Medical Director and approved by the Deputy Secretary for Children’s Medical Services who is a board-certified pediatrician. Preventive Care Standards • CMS providers are expected to use the American Academy of Pediatrics’ well-child supervision standards and the periodicity schedule. Quality Reviews CMSN contracts for peer review through a panel of physician consultants. The physician consultants in coordination with CMSN health care staff review, at a minimum:  medical record content to determine appropriateness of care;  compliance with program standards; and  family perception of care. The CMS will also be a part of the Florida Healthy Kids Corporation evaluation.