Page 52

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 7-52

Effective Date: 07/01/05

52 Approval Date: _____________/06 MCO or PCCM provider is responsible for the provision of services regardless if a medical condition and/or diagnosis was present prior to being assigned the enrollee, thus the MCO or PCCM provider will manage all pre-existing conditions. The health plans provide access to all covered services, including specialty services, to any child regardless of medical condition. MCOs cover and pay for services furnished in facilities or by practitioners outside the plan’s network if the needed medical services or necessary supplementary resources are not available in the plan’s network.

MCOs and PCCM providers are not permitted to refuse an assignment or disenroll a patient or otherwise discriminate against a patient based on physical or mental handicap or type of illness or condition.

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))

Prior authorization of health decisions will be made in accordance with State law consistent with the standards set by the regulations governing managed care health insurance plans.

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Page 52

Official source

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 7-52

Effective Date: 07/01/05

52 Approval Date: _____________/06 MCO or PCCM provider is responsible for the provision of services regardless if a medical condition and/or diagnosis was present prior to being assigned the enrollee, thus the MCO or PCCM provider will manage all pre-existing conditions. The health plans provide access to all covered services, including specialty services, to any child regardless of medical condition. MCOs cover and pay for services furnished in facilities or by practitioners outside the plan’s network if the needed medical services or necessary supplementary resources are not available in the plan’s network.

MCOs and PCCM providers are not permitted to refuse an assignment or disenroll a patient or otherwise discriminate against a patient based on physical or mental handicap or type of illness or condition.

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))

Prior authorization of health decisions will be made in accordance with State law consistent with the standards set by the regulations governing managed care health insurance plans.