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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998 127 Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/05, 8/11/05, 10/1/06, 7/1/09, 7/1/10, 7/1/11, 7/1/12 for FHKC’s decision, 3) an explanation of applicable right to review of that determination, 4) the standard and expedited time frames for review, 5) the manner in which a review may be requested, and 6) the circumstances under which enrollment may continue pending review.

The resolution coordinator should involve all parties necessary to resolve the applicant/participant’s dispute. Disputes that substantively involve more than one KidCare entity should be immediately referred to the KidCare Grievance Committee. The resolution coordinator must notify the applicant/participant of the referral to the KidCare Grievance Committee in writing.

The resolution coordinator (or designee) will acknowledge receipt of the dispute within three (3) calendar days of receipt. Resolution of the dispute shall be sent to the applicant/participant in writing within fifteen (15) calendar days after FHKC’s receipt of a written request to initiate the dispute review process.

The resolution coordinator may extend the time frames listed above to accommodate any necessary additional research, or for other appropriate reasons. The applicant/participant shall be promptly notified of any extension. Every effort will be made to prevent such an extension from lasting longer than 30 days. The resolution coordinator shall make every effort to ensure that no dispute review process remains unresolved longer than 90 days.

Pursuant to 42 CFR 457.1140(d)(1)(2) and (3), Florida KidCare developed this review process to ensure that any applicant/enrollee has the opportunity to represent themselves or have representatives of their choosing involved in the review process. In addition, applicants and enrollees are entitled to timely review of their files and any other applicable information relevant to the review of the pending decision, and to participate in the review process, whether in person or in writing. All reviews must be completed within 90 days. For details about the review process, please see the enclosed Dispute Review Process. All decisions are written consistent with 42 CFR 457.1140 (c).

The Florida KidCare Dispute Review Process and Grievance procedures are included in Appendix B and C.

Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR §457.1120.

Assurances • The Florida KidCare program has a process for program specific review that meets the