Page 20

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

Effective Date:

Approval Date: 20 according to OHP Medicaid FFS protocols and claims are subject to SURS post-payment review.

The OPHP private market carrier contract will require that the carriers have quality assurance rules and a quality improvement review process in place to ensure that the services provided are appropriate and medically necessary. It will include an internal utilization review infrastructure that monitors utilization of preventive care, the operation and outcome of referral procedures, and persistent or significant Healthy KidsConnect enrollee/guardian complaints.

Carriers require prior authorization for certain services according to the guidelines developed in accordance with its Care Management Department’s requirements.

Healthy KidsConnect quality assurance staff annually review health plan compliance against utilization and quality assurance requirements to ensure appropriate structures are in place to monitor utilization of health care services.

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Page 20

Official source

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

Effective Date:

Approval Date: 20 according to OHP Medicaid FFS protocols and claims are subject to SURS post-payment review.

The OPHP private market carrier contract will require that the carriers have quality assurance rules and a quality improvement review process in place to ensure that the services provided are appropriate and medically necessary. It will include an internal utilization review infrastructure that monitors utilization of preventive care, the operation and outcome of referral procedures, and persistent or significant Healthy KidsConnect enrollee/guardian complaints.

Carriers require prior authorization for certain services according to the guidelines developed in accordance with its Care Management Department’s requirements.

Healthy KidsConnect quality assurance staff annually review health plan compliance against utilization and quality assurance requirements to ensure appropriate structures are in place to monitor utilization of health care services.