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

Effective Date:

Approval Date: 34 Case Manager (in order to be eligible, patient must be confined to a licensed mental health bed and treated by an eligible mental health provider) for the following: residential treatment in a psychiatric setting, urgent admissions, chemical dependency, psychological testing (except when included in the hospital's or treatment program's daily charge, hypnotherapy, sodium amytal interviews, electroconvulsive treatment; stress, relaxation and occupational therapies (except when included in the hospital's or treatment program's daily charge); psychosurgery.

6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

More than 26 outpatient visits per plan year (combined with outpatient substance abuse visits) require precertification from the Mental Health Case Manager (patient responsible for keeping track of the number of visits); psychological testing over and above that performed during the 26 visits will also require pre-certification from the Mental Health Case Manager.

6.2.12.

Durable medical equipment and other medically related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

Must be standard equipment that is normally used in an institutional setting, able to withstand repeated use, primarily and customarily used to serve a medical purpose, generally not useful in the absence of an illness or injury, appropriate for use in the home (such as a standard hospital bed, standard wheelchair, nebulizer, etc.) and not used for the convenience of the caregiver, reasonable and medically necessary for the treatment of a specific illness or injury.

VISION: Scheduled routine eye examinations once every 12 months, eyeglass lenses or contact lenses once every 12 months, routine replacement of eyeglass frames once every