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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 - 32 - MO HealthNet Managed Care Delivery System The contract with the MCOs include service accessibility standards for 24- hour coverage, prior authorization, travel distance standards, appointment standards, and care management. The monitoring of the standards is further outlined in the QI Strategy. In addition, the MCO shall have established written policies and procedures concerning: • How a member may obtain a referral to an out-of-network provider when the MCO does not have a health care provider with appropriate training or experience in the network to meet the particular health care needs of the member; • How a member, with a condition which requires on-going care from a specialist, may request a standing referral to such a specialist; and • How a member, with a life-threatening condition or disease, either of which requires a specialized medical care over a prolonged period of time, may request and obtain access to a specialty care center. The MCO must provide adequate access to physician specialists for PCP referrals and employ or contract with physician specialists in sufficient numbers to ensure specialty services can be made available in a timely manner. The MCO shall have protocols for coordinating care between PCPs and specialists which include the expected response time for consults between PCPs and specialists. 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)) (42 CFR 457.495(d)) Response MO HealthNet Fee-For-Service Delivery System