Page 40

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

Effective Date: August 24, 2001

Approval Date: 40 obtained by SCHIP clients for fraud and abuse. This will provide the SCHIP program a capacity for the full investigation, referral to appropriate law enforcement, and reporting of sanctions as required. The SURS is the designated unit in the Department of Social Services for investigation of fraud, and collaboration with the South Dakota Attorney General’s office and U.S. Attorney. A toll free fraud reporting telephone number is also available to provide a convenient means to report fraud.

Surveys and quality assurance reports will also be used to monitor the quality and appropriateness of services provided the SCHIP clients. Client surveys have been an important part of the SCHIP annual reporting that has been completed by South Dakota for each year of the SCHIP program. . Specific questions are addressed to the families of SCHIP children asking about the quality and satisfaction that families have with the services provided. These surveys and the specific questions will continue under the Medicaid and SCHIP programs.

A number of quality assurance reports based on the HEDIS model have been completed for the SCHIP eligible children covered under South Dakota’s SCHIP program. These reports specifically address the key areas of immunization, well child and well baby. In addition to reports on those subjects reports have been completed on Dental, Optometry, Asthma, Substance Abuse, and Eating Disorders. Plans include repeating these measure to monitor progress and also to expand the number of measures under the HEDIS to be completed for the SCHIP children in South Dakota.

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

7.1.1. X Quality standards

The state will establish standards for the performance of PCP’s to meet for the well child screenings and immunization levels for children in the CHIP NM program.

7.1.2. X Performance measurement

The state will conduct HEDIS based measurement studies for immunization, dental, well child screenings, optometry, substance abuse and mental health services. 7.1.3. ∼ Information strategies 7.1.4. ∼ Quality improvement strategies

7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)