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Effective Date: April 1, 2009

Approval Date: ____________ 43

Access to emergency services is monitored as part of the independent PRO review and by reviewing claim denials, complaints and grievances.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee's medical condition. (Section 2102(a)(7)) (42CFR 457.495(c)) The State employs monitoring and other methods to assure that appropriate and timely treatment is provided to enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee's medical condition. The HMO contract requires such activities. The State staff monitors contract compliance, as does the PRO.

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)) (42CFR 457.495(d)) Decisions related to the prior authorization of health services are completed in accordance with state law, regulation and HMO contract provisions, or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. The State employs monitoring and other methods to assure that appropriate and timely treatment is provided to all enrollees, including those enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee's medical condition. The HMO contract requires such activities. The State staff monitors contract compliance, as does the PRO.