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Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 13 - Response: Utilization controls for targeted low-income children will vary depending on the health care delivery system from which targeted low-income children receive healthcare. MO HealthNet Fee-For-Service Delivery System The MO HealthNet utilization review program in the fee for service setting has a multi- prong approach very similar to those used by the MO HealthNet Managed Care delivery system. Utilization management programs in place includes pre-certification allowing payment for services and equipment that are medically necessary, appropriate, and cost- effective without compromising the quality of care to those served in the fee-for-service setting. The MO HealthNet Division has introduced an electronic health record program. The online tool called CyberAccess sm is available to request or check status of a pre- certification request. An innovative Electronic Health Record (EHR) program for MO HealthNet recipients is available to their healthcare providers. The web-based tool allows physicians to prescribe electronically, view diagnosis data, receive alerts, select appropriate preferred medications, and electronically request drug and medical prior authorizations for their fee-for-service patients. CyberAccess sm is the first step toward a comprehensive electronic health record for MO HealthNet recipients. In addition, the MO HealthNet Division contracts for utilization review of inpatient stays. The contractor's medical review staff must make decisions for inpatient hospital admission and continued stays in accordance with the Severity of Illness/Intensity of services screening criteria (using the most recent edition of the InterQual ISD Pediatric Acute Level of Care and Adult Level of Care) based on pertinent medical information received from the attending physician or hospital regarding the patient's condition and planned services, and in the case of continued stay reviews, whether any further care planned may be safely provided in a post hospital setting. The Department of Health and Senior Services operates a Healthy Children and Youth (HCY) Administrative Case Management Program assists families in meeting their child's needs to function at an optimal level. Assistance is provided for:  Access to screening services  Follow-up on referrals to additional medical providers  Establishment of a medical home  Service plan development  Follow through on the treatment plan