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Title 5: Centrally Administered Programs Page 8 Iowa Department of Human Services Employees’ Manual Chapter E: Healthy and Well Kids in Iowa (hawk-i) General Administration Revised July 3, 2009 Appeals Health or Dental Services Appeal Process Legal reference: 441 IAC 86.15(7) Appeals concerning health or dental services provided through providers contracted with a participating hawk-i health or dental plans are handled by the participating plan. The appeal process includes: ♦ Sending an acknowledgement of receipt of the appeal to the enrollee. ♦ Establishment of time frames to ensure that appeals will be resolved within 60 days, except for appeals that involve emergency medical conditions. Appeals involving emergency medical conditions shall be resolved within time frames appropriate to the situations. ♦ Ensuring the participation of persons with authority to take corrective action. ♦ Ensuring that the decision be made by a physician or clinical peer who has not previously been involved in the case. ♦ Ensuring the confidentiality of the enrollee. ♦ Ensuring issuance of a written decision to the enrollee for each appeal. The decision shall contain an adequate explanation of the action taken and the reason for the decision. ♦ Maintaining an appeal log that is made available to the Department. ♦ Ensuring that the participating health and dental plan’s written appeal procedures are provided to each newly covered enrollee. ♦ Requiring that the participating health and dental plans make quarterly reports to the Department summarizing appeals and resolutions.