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

Effective Date: August 24, 2001

Approval Date: 39

The state also monitors the performance of each PCP with regard to the number of clients enrolled with each PCP, the proportion of services provided directly or referred by each PCP, and the satisfaction of clients with PCPs via a complaint and disenrollment process used by recipients to change PCP’s. Case file reviews will be conducted on quality complaints. This program operates for Medicaid recipients under waiver authority from CMS. The waiver process provides for a biannual review of the program by CMS, and a number of focussed clinical studies to be completed each renewal period. Monitoring of this program by CMS has been ongoing since 1993, with the third and most recent renewal expiring September 30, 2002. . South Dakota will request the managed care waiver be incorporated into its Medicaid and SCHIP state plans. All of the quality and appropriateness monitoring available to Medicaid for the PCCM program will also be provided to the SCHIP program.

External reviews of medical, surgical and hospital services are conducted by the Professional Review Organization (PRO) in South Dakota. A large sample of services is selected for review each month on a variety of criteria, including specific diagnoses and random selections. Services provided to SCHIP clients will also be included in the sample selected for PRO review. The PRO reports to each provider and to the State the results of each review recommending approval, denial, changes or improvements to service delivery, action by the Medicaid program or referral to other entities for action.

Drug utilization review activities will also be made available to SCHIP clients through the pharmacy benefit management system used by the Department to provide prescription drug coverage. Each drug prescription is processed through a prospective drug use review protocol prior to authorizing a pharmacist to dispense a drug product. This point of service process checks for drug to drug interactions, contraindications, duplicate therapy, dosage, early refill, and days-supply edits to help assure appropriate and quality prescription drug services. The drug utilization review requirements are purchased from a national vendor and incorporated into the Department’s system. A licensed pharmacist employed by the Department oversees the operation of the DUR system.

The SCHIP program will also make use of the capabilities of the MMIS claims processing system to process and pay claims for SCHIP clients using the same procedures and rates as the Medicaid program. The MMIS claims systems has numerous edits, reports and capabilities to assist in assuring appropriate and quality services are delivered to SCHIP clients. The MMIS is the source for the Medicaid reporting of EPSDT screening services to CMS, and these reporting capabilities will be available to report on the SCHIP children also.

Surveillance and utilization review system (SURS) capabilities used by the Department to monitor Medicaid services will also be used to monitor the services