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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998 135 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 Florida KidCare Program. The Florida Healthy Kids Corporation Resolution Staff is responsible for conducting the Florida KidCare Dispute Review Process.

The Florida KidCare Dispute Review Process is comprised of four review levels addressing the denial of eligibility, failure to make a timely determination of eligibility and suspension or termination of enrollment, including disenrollment for failure to pay the family premium. The Florida Healthy Kids Corporation shall provide information regarding the dispute review process in correspondence to families, making them aware of the existence and availability of the Florida KidCare Dispute Review Process.

Definitions

(1) “Applicant” refers to a parent or guardian of a child or a child whose disability of nonage has been removed under Chapter 743, F.S., who applies for eligibility under Sections 409.810- .820, F.S. (Florida KidCare Act).

(2) “Complaint” or “dispute” is a verbal or written expression of dissatisfaction, regarding an eligibility or enrollment decision received within 90 calendar days of the date of the letter indicating the suspension or termination of a child’s enrollment.

(3) “Complainant” or “grievant” is a parent, legal guardian, an authorized representative of the parent or legal guardian or a child whose disability of nonage has been removed who submits a complaint or grievance on behalf of an applicant, enrollee or former enrollee of the Florida KidCare Program. If a parent, legal guardian or a child whose disability of nonage has been removed appoints a representative to discuss the complaint or grievance on their behalf, they must complete and sign an Appointment of Representation Form, AHCA Med-Serv Form 017, August 2007, one page, and the Authorization for the Use and Disclosure of Protected Health Information Form, AHCA Med-Serv Form 018, August 2007, two pages, which are incorporated by reference. These forms name the representative and give the representative access to medical records in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

(4) “Enrollee” means a child who has been determined eligible for and is receiving coverage under Sections 409.810-.820, F.S.

(5) “Grievance” means a formal written complaint initiated to challenge an eligibility or enrollment decision only after all other forms of resolution have been exhausted through the Florida KidCare Formal Dispute Review Process.