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Model Application Template for the State Children’s Health Insurance Program
Effective Date:
Approval Date: 6-4 person; or (D) serious disfigurement of such person.
Level of Coverage: No limitations.
6.2.3.
Physician Services (Section 2110(a)(3))
● Pediatric Health Promotion visits.
Scope of Coverage: Well child care visits in accordance with a visitation schedule established by American Academy of Pediatrics and the Childhood Immunization Schedule of the United States will be followed for immunizations.
Level of Coverage: Includes all services related to visits. Includes immunizations, well child care, health education, tuberculin tests (Mantoux), hearing tests, dental and developmental screening, clinical laboratory and radiological tests, eye screening, and lead screening.
● Professional Services for Diagnosis and Treatment of Illness and Injury
See Section 6.2.2.
● Professional Services for Diagnosis and Treatment of Illness and Injury
See Section 6.2.2.
6.2.4.
Surgical Services (Section 2110(a)(4))
● Please refer to Section 6.2.1. Inpatient Services; Section 6.2.2. Outpatient Services; and Section 6.2.28 Maternity Services
● Pre-surgical testing
Scope of Coverage: All tests, (laboratory, x-ray, etc) necessary prior to inpatient or outpatient surgery.
Level of Coverage: Benefits are available if a physician orders the tests; proper diagnosis and treatment require the tests; and the surgery takes place within 7 days after the testing. If surgery is cancelled because of pre-surgical test findings or as a result of a second opinion on surgery, the cost of the tests will be covered.