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

Effective Date:

Approval Date: 27 7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

The State of Idaho will ensure access to appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition.

Contractually, primary care providers are required to make referrals for most medically necessary specialty services. All provider types necessary to provide covered services are included in the provider panel. In addition, Healthy Connections Representatives (primary care case management program coordinators) work with enrollees and providers to help ensure appropriate covered services are provided.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

Decisions related to prior authorization of health services will be completed in accordance with State law and/or Administrative Rule and the medical needs of the patient.