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

Effective Date:

Approval Date: 7-7

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))

Health plans must develop and have in place utilization review policies and procedures that include protocols for prior approval and denial of services, hospital discharge planning, physician profiling, and retrospective review of both inpatient and ambulatory claims meeting pre-defined criteria. Health plans must complete prior authorization of health services in accordance with the medical needs of the member and within 14 days after the receipt of a request for services. Health plans also must develop procedures for identifying and correcting patterns of over- and under-utilization on the part of their enrollees.