Page 11

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

Effective Date:

Approval Date: 11

This State Plan uses utilization controls from the Title XIX program, including prior approval controls, peer reviews, claims processing edits, post-audit and review procedures. Primary care providers are charged with making referrals for medically necessary specialty services. Health services providers are provided a handbook describing the benefit package including limitations. Participants are issued an identification card delineating the applicable benefit package. The card is used to determine covered services and service limitations.