Page 35

Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

35

Many of these requirements are evaluated initially upon licensure; upon request for service area expansion; and periodically through complaint and grievance monitoring,

on-site visits by Department of Health staff, external reviews by NCQA, and various quarterly and annual reports addressing the provider delivery systems of the CHIP Contractors.

As part of the annual re-contracting process, Contractor health service delivery system information is assessed to assure an adequate number and distribution of providers and facilities of all types.

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

Primary care, including well-child care is provided in accordance with the schedule established by the American Academy of Pediatrics. Services related to those visits, include, but are not limited to, immunizations, health education, tuberculosis testing and developmental screening in accordance with routine schedule of well- child visits. Care must also include a comprehensive physical examination, including X-rays if necessary, for any child exhibiting symptoms of possible child abuse.

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))

Contractors must establish and maintain adequate provider networks as determined by the Department of Health to serve all eligible children who are or may be enrolled, to include, but not be limited to: hospitals, children’s tertiary care hospitals, specialty clinics, trauma centers, pediatricians, specialists, physicians, pharmacies, dentists, substance abuse treatment facilities, emergency transportation services, rehab facilities, home health agencies and DME suppliers in sufficient numbers and geographic dispersions to make available all services in a timely manner. Covered services must be provided out-of-network if such services are not available in a timely and accessible manner through in-network providers. In accordance with Article XXI Section 2111, of Act 1998-68, and 28 Pa. Code Sections 9.679(D) and 9.679(E), the contractor must have adequate health care available in a timely and accessible manner through its network providers. Contractors not utilizing provider networks shall implement procedures to ensure these standards are met by providers providing coverage to their enrollees.