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After the insurer’s internal review is completed, the parent of an enrollee who disagrees with the decision may request further review by submitting a letter or form to the State Division of Insurance Administration. The Appeals Coordinator within the Division will review the matter and gather supplemental information from the family, physician, and/or insurer as needed. The Appeals Coordinator may also request review by the by state’s independent medical consultant. Reviews generally are completed within 16 days and the member will be notified in writing of the decision. It is anticipated that most appeals will be resolved either through the insurer’s internal process or at this level.

If the appeal is not resolved, the request will be scheduled for impartial review by the CoverKids Review Committee. The Committee will meet once per month to consider any appeals and will be composed of five members, including Division of Insurance Administration staff and at least one licensed medical professional, selected by the Commissioner or his designee. The parent will be given the opportunity to review the file, provide supplemental information and appear in person. The parent will receive written notification of the final decision, normally within one week from the date of the Committee meeting. The decision of the CoverKids Review Committee is the final recourse available to the member.

Internal and external reviews will be completed within 90 days. Reviews by both the Appeals Coordinator and the Committee may be expedited (completed within 72 hours) 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. All required notices, including the final notice of the results from the CoverKids Review Committee, will be issued within the specified timeframes (90-days or 72 hours, as applicable). Notices for denials, delays, reductions, suspensions, or terminations in providing or paying for health services and for failures to approve, furnish or provide payment in a timely manner 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

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