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Title 5: Centrally Administered Programs Page 7 Iowa Department of Human Services Employees’ Manual Chapter E: Healthy and Well Kids in Iowa (hawk-i) General Administration Revised July 3, 2009 Appeals Appeals Legal reference: 42 CFR 431.200, 431.220, 441 IAC 7.5(217) and 86.12 The applicant or enrollee has a right to appeal any decision or action, regardless of the decision, and to request an appeal hearing. No one may limit or interfere with this right. All appeal requests must be forwarded to the Department’s Appeals Unit. This unit will decide if a hearing will be granted.

1. Mrs. A is unhappy that the TPA’s call center is not open on Saturdays so she can talk to a real person, and she tells the call center staff that she wants to appeal that fact. The call center staff person does not tell Mrs. A that she cannot appeal the operating hours. Instead, the staff person informs Mrs. A how to file an appeal. When Mrs. A files her appeal request with the TPA, the appeal request is forwarded to the Appeals Unit within the designated time frames. 2. Mr. B’s hawk-i application is approved. Because his application was received in May, hawk-i coverage is approved June 1. Mr. B files an appeal request with the TPA because he wanted hawk-i coverage to begin May 1, instead of June 1. The TPA forwards Mr. B’s appeal request to the Appeals Unit within the designated timeframes. Examples of adverse actions in which a hearing may be granted include, but are not limited to: ♦ The denial or cancellation of coverage under the hawk-i program. ♦ A delay in acting on an application or renewal with reasonable promptness. ♦ The amount of the premium. ♦ The effective date of coverage. The third-party administrator represents the Department in appeal hearing regarding hawk-i eligibility. See 1-E, APPEALS AND HEARINGS, for a complete explanation of the Department’s appeal process, including TPA and enrollee or applicant responsibilities, time limits, and appeal decisions. Appeals regarding covered services are handled by the health plan in which the child is enrolled. Such appeal requests received by the TPA should be forwarded to the appropriate health plan within one business day of receipt.