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

Effective Date:

Approval Date: 7-5 ● Description of quality assurance committee structure; ● Identification of departments/individuals responsible for QAP implementation; ● Description of manner in which network providers may participate in QAP; ● Credentialing/re-credentialing procedures; ● Standards of care; ● Standards of service accessibility; ● Medical records standards; ● Utilization review procedures; ● Quality indicator measures and clinical studies; ● Quality assurance plan documentation methods; and ● Description of the manner in which quality assurance/quality improvement activities are integrated with other management functions.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

Emergency Services: In order to insure that members have access to covered services, including emergency services, in addition to maintaining adequate networks, health plans are prohibited from requiring members to seek prior authorization for services in a medical or behavioral health emergency. Health plans must inform their members that access to emergency services is not restricted and that if the member experiences a medical or behavioral health emergency, he/she may obtain services from a non-plan physician or other qualified provider, without penalty. However, health plans may require members to notify the plan or their PCP within a specified time after receiving emergency care and may require members to obtain prior authorization for any follow- up care delivered pursuant to the emergency.

Twenty-Four (24) Hour Coverage: Health plans must provide coverage to members, directly or through their Primary Care Providers (PCPs), twenty-four (24) hours a day and seven (7) days a week. Health plans must instruct their members on how to obtain services after business hours and on weekends.

Telephone Access: Health plans may require their PCPs to have primary responsibility for serving as after hours “on-call” telephone resource to members with medical problems. If the PCP performs this function, he/she cannot be permitted to “sing-out” (i.e., automatically refer calls) to an emergency room.

Whether or not the health plan assigns primary responsibility for after hours telephone access to a PCP, it must have a twenty-four hour toll free telephone number for members to call which is answered by a live voice (answering machines are not acceptable).

The Department monitors access to services and the adequacy and appropriateness of provider networks several ways. To ensure the adequacy and availability of insurer provider networks, the Department requires all health plans to submit electronically, on a quarterly basis, the complete provider and service networks by county. These submissions are reviewed by the Department to monitor the adequacy of network in terms of provider composition including, but not limited to, the availability of specialty providers as well as primary care providers and office sites and hours of operation. If