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

Effective Date:

Approval Date: 53 the consumer.

Benefit plans need not include an out-of-network benefit except for emergencies. The Healthy KidsConnect benefit plan excludes any out- of-network benefit except for emergencies or in cases for which the insurer provides a prior authorization. When out-of-network providers are authorized or emergent, the insurers will cover them as in network services.

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)) CHIP OHP Plus: DMAP requires PHPs to make a determination on authorization requests within two working days of receipt of an authorization or reauthorization request related to urgent services; alcohol and drug services; and/or care required while in skilled nursing facility. Authorizations for prescription drugs must be completed and the pharmacy notified within 24 hours. If an authorization for a prescription cannot be completed within the 24 hours, the PHP must provide for the dispensing of at least a 72 hour supply if the medical need for the drug is immediate.

For all other pre-authorization requests, PHPs shall notify providers of an approval, a denial or a need for further information within 14 calendar working days of receipt of the request.

Healthy KidsConnect: private Plans are required by DCBS OAR to respond to requests for prior authorization of nonemergency services within two business days and must have qualified health care personnel available for same day telephone responses to inquiries concerning certification of continued length of stay. Emergency services do not require prior authorization.