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Reviews of general eligibility and enrollment matters will be completed within a 90-day timeframe. Expedited reviews will be completed within 10 days from the initial receipt of the request for review. The appropriate notices will be issued within those timeframes. Notices for denials, suspension, or termination of enrollment, or failure to make a timely eligibility determination will include information on the reasons for the determination, an explanation of applicable rights to review of that determination, the standard and expedited timeframes for review, the manner in which review can be requested and the circumstances under which enrollment may continue pending review.

The State assures that in the review process, enrollees have the opportunity to fully participate in the review process (including representing themselves or have representatives of their choosing in the review process) and review information relevant to the review of the decision in a timely manner; decisions are made in writing; impartial reviews are conducted in a reasonable amount of time and consideration is given for the need for expedited review when there is an immediate need for health services. Enrollees will remain enrolled pending completion of the review in the case of suspension or termination of enrollment.

Health Services Matters

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

For health services matters, CoverKids will use a process that includes both internal review by the insurer and external review by the State Division of Insurance Administration. The State’s contract with the insurer will require the insurer to have grievance/complaint procedures for denials, delays, reductions, suspensions, or terminations in providing or paying for health services and for failure to approve, furnish or provide payment in a timely manner. These procedures must include participation by a pediatrician in the review, must be followed prior to appealing to the state, and must be completed within 30 days. Expedited reviews (within 72 hours) will be available for situations in which a benefit determination or a preauthorization denial has been made prior to services being received and the attending medical professional perceives the medical situation to be life threatening or would seriously jeopardize the enrollee’s health or ability to attain, maintain or regain maximum functioning.

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