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

Effective Date:

Approval Date: 30 require prior authorization and physician prescription for outpatient services.

CHIP Perinatal Program: • Covered, medically necessary outpatient services are limited to those outpatient services that directly relate to prenatal or postpartum care and/or the delivery of the covered unborn child until birth. • Outpatient observation is a covered benefit under the CHIP Perinatal Program. • Ultrasound of the pregnant uterus is a covered benefit of the CHIP Perinatal Program when medically indicated. Ultrasound may be indicated for suspected genetic defects, high-risk pregnancy, fetal growth retardation, or gestational age conformation. • Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion (FIUT) and Ultrasonic Guidance for Amniocentesis, Cordocentrsis, and FIUT are covered benefits of the CHIP Perinatal Program with an appropriate diagnosis. • Coverage for the CHIP Perinatal newborn is the same as coverage for CHIP clients.

6.2.3.

Physician services (Section 2110(a)(3)) Covered, medically necessary physician and physician extender services are unlimited and include, but are not limited to, the following: American Academy of Pediatrics recommended well-child exams and preventive health services (including but not limited to vision and hearing screening and immunizations); physician office visits; inpatient and outpatient services; laboratory, x-rays, imaging and pathology services and professional interpretation; medications, biologicals and materials administered in the physician’s office; allergy testing, serum and injections; (in/outpatient) surgical services, including surgeons for surgical procedures including appropriate follow- up care, administration of anesthesia by physician (other than surgeon) or CRNA, second surgical opinions, same-day surgery performed in a hospital without an over-night stay; invasive diagnostic procedures such as endoscopic examination; hospital-based physician services (including physician-performed technical and interpretative components); and, in-network and out-of-network physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section.

Exclusions to physician services include: infertility treatments, prostate and mammography screening; reproductive services