600 APPEALS PROCESS

600.1 Applicants shall be notified of any action regarding the eligibility and enrollment status and cost sharing requirements for the enrollees’ participation in the Children’s Basic Health Plan and appeal rights regarding those actions by the Department or its designee. 600.2 The Department or its designee shall notify the applicant within ten (10) business days of a decision regarding eligibility, enrollment and cost sharing. The notice shall: A. Be in writing; B. Be in his/her primary language, to the extent practicable; C. Describe to the applicant the reasons for the decision; D. Document the authority for the decision (e.g. rule citation); and E. Inform the applicant of his/her rights and responsibilities regarding the decision. 600.3 An applicant who disagrees with a denial regarding eligibility, enrollment, or cost sharing requirements may appeal in writing to the Children’s Basic Health Plan Eligibility Vendor within thirty (30) calendar days of the date of the notification of denial of eligibility, enrollment, or cost sharing. The appeal shall be reviewed and processed within thirty (30) calendar days of receipt and the results of the appeal shall be communicated to the applicant within ten (10) business days of the review. The following guidelines shall apply to the appeal process: A. The Children’s Basic Health Plan Eligibility Vendor will coordinate the appeals process with the county or Eligibility site that determined the initial eligibility, enrollment, or cost sharing decision within ten (10) business days after receipt of the appeal. B. The county or Eligibility site that determined the initial eligibility, enrollment, or cost sharing decision shall: 1. Review the data entry of the application in the Department’s eligibility system for accuracy and completeness within ten (10) business days after receipt of the appeal from the Children’s Basic Health Plan Eligibility Vendor; 2. Correct or complete information in the Department’s eligibility system if it is found to be incomplete or incorrect and re-run eligibility; 3. Maintain the original denial, if the information in the Department’s eligibility system is complete and correct; and 4. Notify the applicant and the Children’s Basic Health Plan Eligibility Vendor in writing once the review is complete with the results of the data entry review and the option of forwarding the appeal to the Grievance Committee. 600.4 If the applicant disagrees with the results of the appeal, the applicant may have their appeal reviewed by the Grievance Committee. The Grievance Committee’s decision shall be final. A. The Grievance Committee shall be conducted by an independent panel appointed by the Executive Director of the Department. The panel shall include at least three people from the Department or its designee not previously involved with the grievance. A person previously involved with the grievance may be present at the conference and appear before the panel to present information and answer questions, but shall not have a vote. The Department shall ensure that those appointed to the panel have sufficient experience to make an informed decision regarding the grievance under review. B. The applicant may attend the Grievance Committee in person or by telephone. C. The applicant may be represented by the person of the applicant’s choice (i.e. legal counsel, friend, family member, etc.) during the Grievance Committee. D. The applicant may have access to documents that were used by the Department or its designee in making the decision under appeal. 600.5 An enrollee who disagrees with a denial of benefits shall submit an appeal to the MCO he/she is enrolled in and shall follow the MCO’s appeal process.