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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998 128 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 requirements of §§457.1130, 457.1140, 457.11450, 457.1160, 457.1170, and 457.1180.

• All Florida KidCare applicants or enrollees have the opportunity for independent review consistent with §§457.1140 and 457.1150, of a health services matter, such as delay, denial, reduction, suspension, or termination of health services, in whole or in part, including a determination about the type or level of services; and failure to approve, furnish, or provide payment for health services in a timely manner, unless the sole basis for the decision is a provision in the Florida KidCare State Plan or in Federal or State law requiring an automatic change in eligibility, enrollment, or a change in coverage under the health benefits package that affects all applicants or enrollees or a group of applicants or enrollees without regard to their individual circumstances. If there is an immediate need for health services, the State will provide an expedited review.

• Florida KidCare assures that reviews related to health service matters are conducted by an impartial person or entity in accordance with §457.1150; review decisions are timely in accordance with §457.1160; review decisions are written; and applicants and enrollees have an opportunity to represent themselves or have representatives of their choosing in the review process; timely review their files and other applicable information relevant to the review of the decision; fully participate in the review process, whether the review is conducted in person or in writing, including by presenting supplemental information during the review process and receive continued enrollment in accordance with §457.1170.

• Florida KidCare assures that an enrollee has an opportunity for an independent external review of matters described in §457.1130(b). External reviews are conducted by the State or by a contractor, other than the contractor responsible for the matter subject to external review.

• Florida KidCare ensures that reviews are completed in accordance with the medical needs of the patient. If the medical needs of the patient do not dictate a shorter time frame, reviews are completed within the time frames set forth in §457.1160: within 90 calendar days of the date an enrollee requests the review; or within 72 hours if the enrollee’s physician or health plan determines that operating under the standard time frame could jeopardize the enrollee’s life or health or ability to attain, maintain or regain maximum function. Florida KidCare may extend the 72-hour period by up to 14 calendar days if the enrollee requests an extension.