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

Effective Date:

Approval Date: 19 consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b)) Oregon Administrative rules for quality assurance and quality improvement review process require DMAP contracted prepaid health plans to have an internal utilization review infrastructure and to specifically monitor utilization of preventive care, the operation and outcome of referral procedures, and persistent or significant DMAP member complaints. DMAP staff annually reviews health plan compliance with utilization and quality assurance requirements to ensure appropriate utilization of health care services. The quality improvement process ensures services provided are appropriate and medically necessary, and approved by the state. The following are examples of administrative mechanisms required of the managed care plans in the Oregon Health Plan Medicaid Demonstration Project, which are also required under CHIP to ensure CHIP children receive appropriate and medically necessary health care.

• Plans must provide 24-hour-a-day, 7 day-a-week appropriate urgent, emergent, and triage services. Plans are required to have written policies and procedures that they communicate to providers, and plans are required to review their policies and procedures annually. • Plans must ensure and monitor the availability of an after-hours call- in system to triage urgent and emergent call from clients. • Plans must assure access to services according to the following time standards: • Immediately for emergency medical services. Within 24 hours for emergency dental, mental health, or chemical dependency services. • Within 48 hours for urgent medical, mental health, or chemical dependency services. Within one to two weeks for urgent dental services. • Within four weeks, or within the community standard, for well care for preventive or non emergent medical services. • Within two weeks of patient request for intake assessment for mental health or chemical dependency services. • Within twelve weeks, or the community standard, for dental services.

For CHIP services provided on a FFS basis, all utilization review requirements of Title XIX and the 1115 Demonstration apply. The Quality Improvement Organization (QIO) contractor reviews inpatient hospital services. DMAP requires prior authorization for certain services