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Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 51 - • Meets the criteria for an expedited appeal process but was not resolved using the MCOs expedited appeal timeframes, or • Was resolved wholly or partially adversely to the member using the MCOs expedited appeal timeframes. Expedited resolution (if the appeal was made directly to the State fair hearing process without accessing the MCO appeal process): within three working days from the state agency’s receipt of a hearing request for a denial of a service that meets the criteria for an expedited appeal process. Health Services Matters 12.1 Please describe the review process for health services matters that complies with 42 CFR part 457.1120. Response: Missouri maintains an independent State fair hearing process as required by federal law and regulation, as amended for MO HealthNet, SCHIP 1, and SCHIP 2. The State fair hearing process shall provide recipients an opportunity for a State fair hearing before an impartial hearing officer. The parties to the State fair hearing include recipients, his or her representative, or the representative of a deceased recipient's estate, and the MCOs if applicable. The State agency and/or MCO shall comply with decisions reached as a result of the State fair hearing process. MO HealthNet, SCHIP 1, and SCHIP 2 recipients have the right to request information regarding: • The right to request a State fair hearing. • The procedures for exercising the rights to appeal or request a State fair hearing. • Representing themselves or use legal counsel, a relative, a friend, or other spokesperson. • The specific regulations that support or the change in federal or state law that requires the action. • The individual’s right to request a State fair hearing, or in cases of an action based on change in law, the circumstances under which a hearing will be granted. • A State fair hearing within 90 calendar days from the MCO's notice of action. The State must reach its decisions within the specified timeframes: • Standard resolution: • Within 90 calendar days of the date the member filed the appeal with the MCO if the member filed initially with the MCO (excluding the days the