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

Effective Date:

Approval Date: 33 the charge of the second procedure. If the same incision is used, the surgeon will be paid for the one surgical procedure that has the higher UCR allowance. Prior approvals are needed for abdominoplasty, blepharoplasty, cochlear implants, excision of gynecomastia, fimbrioplasty, gastric surgery for morbid obesity, hermaphroditism, keloid excision, nasal structure revision, oral surgery (developmental and congenital orthognathic surgeries, necessitated as a direct result of medical treatment), penile prosthesis, reduction mammoplasty, subcutaneous injection, suction lipectomy, temporomandibular joint (TMJ) dysfunction appliance therapy (limited to injury), transplants, tubotubal anastomsis.

6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

The State Employees Health Plan provides benefits for covered diagnostic services, therapies, laboratory, radiology, and surgeries provided in a hospital outpatient setting or in an ambulatory surgical facility; 1 visit per year between 2 and 7; once every three years between seven and 19 years of age. Immunizations are covered.

6.2.6.

Prescription drugs (Section 2110(a)(6))

6.2.7.

Over-the-counter medications (Section 2110(a)(7))

6.2.8.

Laboratory and radiological services (Section 2110(a)(8))

6.2.9.

Pre-natal care and pre-pregnancy family services and supplies (Section 2110(a)(9))

Prenatal care and childbirth are not covered. Counseling and advice about contraception and prescription drugs for contraception are covered.

6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) (Section 2110(a)(10))

Pre-certification must be obtained from the Mental Health