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19 Effective Date: July 1, 2009

Approval Date: under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

HO plans are required to manage service utilization according to standards in the state’s Quality Improvement Program Standards. Before being approved for participation in the program, health plans must have in place utilization review infrastructure and protocols for, but not limited to: • Determination of medical appropriateness and denial of services; • Referrals to specialty care; • Clinician participation and use of clinical practice guidelines; • Twenty-four hour availability of clinical consultation; • Availability and profiling of practitioners; • Identification of members with chronic/high-risk illnesses, hospital discharge planning, case management, and coordination of special needs; • Access and timeliness of services; and • Review of under or over utilization of care. Internal monitoring reviews will be routinely conducted to assure that medically necessary care is delivered in a cost-effective and efficient manner. External quality reviews, in accordance with federal law (Section 1902 (a) (30) (C) of the Social Security Act), will be conducted annually for selected services by all managed care organizations (MCOs) contracted with the program. Utilization controls for CHIP children on FFS coverage are consistent with all utilization review requirements of Title XIX. Examples of utilization controls include external review of hospital claims data, exception-to-policy procedures, data audits, pre-authorization for extended coverage utilization, and drug utilization review.

Refer to Section 7 – Quality and Appropriateness of Care – for more information on utilization control.