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

Effective Date:

Approval Date: September 19, 2002 36 or concerns they may have. 5. The Department’s peer review organization, conducts prepay and postpay medical records reviews on certain hospital inpatient and outpatient claims. 6. Special reviews are conducted on pharmacy claims to identify duplicate therapy, refill-too-soon, potential drug interactions, and abnormal dosages. Prior approval is required for high risk medication and drugs likely to be abused. 7. Prior approval is required for durable medical equipment and many medical supply items.

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1.

Quality standards

The Department has established quality control mechanisms, including the monitoring of contract compliance, covered services, service delivery, access standards, health education and outreach, coordination with other services, and quality assurance and improvement activities. Specific goals for maintaining quality standards and measures of their attainment are described in Section 9. 7.1.2.

Performance measurement

Performance measures include improving the health status of children by reducing infant mortality, lead poisoning, and school absenteeism; extending health coverage to more Illinois children; and assuring appropriateness of, and access to, necessary health care. These performance measurements and specific criteria for assessing their attainment are more fully described in Section 9. 7.1.3.

Information strategies

The Department is expanding its client health care hotline and promoting the hotline as a place for families to call with concerns and questions. The Department is also incorporating a satisfaction survey for families participating in KidCare. Under both of these efforts, information is being collected and used to directly monitor and improve health care access and quality. 7.1.4.

Quality improvement strategies

The Department is establishing procedures for ongoing quality improvement in written procedures for taking appropriate remedial action and correcting deficiencies.

7.2. Describe the methods used, including monitoring, to assure access to covered