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Effective Date:

Approval Date:

Updated and amended effective August 24, 2001

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• Enrolls the applicant child retroactively to the date that the child should have been enrolled • Re-enrolls an enrollee who has been terminated retroactively to the date the child was terminated

If the management review results in a determination that the decision was appropriate, the Contractor prepares to present facts at the review interview. The Department designates a Review Officer to conduct the eligibility review. The review is an informal process and is not an administrative hearing. The primary objectives of the review are to, where possible, facilitate resolution of the matter at issue and to enroll the child, when appropriate. The Review Officer reviews the application document and verification and the letter of request prior to the conference call in order to become familiar with the case circumstances. Additional documents that may have an impact on the outcome may be submitted by the parent or guardian or their representative. The Reviewer Officer may ask either or both parties for additional documentation, as needed.

A written decision in the form of letter is prepared and sent to the parent or guardian, the representative (if appropriate) and to the Contractor. The Contractor implements the decision of the review officer upon receipt of the letter.

A parent or guardian or representative may request reconsideration of the decision of the review officer if they are dissatisfied with the outcome of the review. A parent or guardian must file a written request for reconsideration with the Insurance Commissioner within 15 calendar days from the date of the Review Officer’s decision. The request for reconsideration must describe the reason(s) upon which the request is made. Requests for reconsideration will stay the action proposed in the decision of the Review Officer (e.g. that coverage should be terminated).

The Commissioner may affirm, amend, or reverse the decision of the review officer. After reviewing the factors considered by the review officer and the request for reconsideration, the Insurance Commissioner will respond in writing to the request. A copy of the reconsideration decision will be sent to the parent or guardian, the representative (if appropriate) and to the Contractor.

A parent or guardian or representative may appeal the decision of the Pennsylvania Insurance Department to Commonwealth Court within 30 days from the date that the Insurance Commissioner responds to the request for reconsideration.

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