Page 60

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 60 Section 12. Applicant and enrollee protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

Eligibility and Enrollment use the same services and systems as those used by the Title XIX program. Recipients receive their notices and options both verbally and in writing; expedited reviews are available at each step.

Health Services Matters

12.2 Please describe the review process for health services matters that comply with 42 CFR 457.1120.

Health services matters use the same services and systems as those used by the State Health Plan as follows:

Two levels of internal review are available for Medical, Pharmacy, and Mental Health disputes. The first level review is by the Claims Processing Contractor. A written report is sent to the member, and if that review is not satisfactory to the member, the second is by a team coordinated by the CPC with medical specialty providers by phone.

The third level review can be made at the choice of the complainant to the Department of Insurance, the State Plan Administrator and Board or an outside medical consultant.

Each level generally requires written response within a maximum of 60 days, however, expedited reviews are available. These substantially shorten the time taken for a decision.

If the individual complainant still has unresolved issues after the process, the member may take the matter up with the Managed Care Patient Assistant Program in the NC Department of Justice. NC law specifically includes both the State Employees Health Plan and the NC Health Choice program included under this jurisdiction.