Page 135
State Children’s Health Insurance Program
Phase 1 Effective Date: April 1, 1998 134 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 Appendix B Florida KidCare Dispute Review Process Title:
Review Process for Eligibility, Enrollment, and Health Services Disputes.
Purpose:
To provide a review process for eligibility, enrollment, and health services disputes submitted by applicants and participants.
Objectives:
To make every effort to thoroughly and equitably conduct a review process for eligibility and enrollment disputes, and a referral process for health services disputes within specified time frames
Policy Statement:
The Florida KidCare Dispute Review Process is the means by which the Florida KidCare Program provides a comprehensive review of complaints relating to eligibility and enrollment. During the review process, complaints or disputes are investigated and resolved for eligibility or enrollment matters regarding: (a) Denial of eligibility; (b) Failure to make a timely determination of eligibility; and (c) Suspension or termination of enrollment, including disenrollment for failure to pay cost sharing.
Health service matter disputes regarding a delay, denial, reduction, suspension, or termination of health services and failure to approve, furnish, or provide payment for health services in a timely manner are reviewed and resolved through a process developed independently for each Florida KidCare program entity as referenced in Rule 59G-14.007, F.A.C.
The Third Party Administrator for the Florida Healthy Kids Corporation determines eligibility and processes informal disputes received during “Level One” of the dispute review process for the non-Medicaid components of the Florida KidCare Program. The Florida Healthy Kids Corporation is responsible for reviewing the formal eligibility and enrollment disputes for the