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

Effective Date:

Approval Date: 68 Conduct of the Review Applicants and members have a right to: 1) represent themselves or have representatives of their choosing participate in the review; 2) timely review their files and other applicable information relevant to the review; and 3) participate fully in the review, whether the appeal is conducted in person, in writing, or by telephone. Disposition of the Review Timely Review. TexCare must complete its decision on the review in a timely manner and furnish a copy of the decision to the applicant or member. The review decision must: 1) state whether the initial adverse action or determination was upheld or reversed and the reasons why; and 2) explain the individual’s right to request a second reconsideration by the Health and Human Services Commission or its designee, of the initial adverse action or determination, and include instructions on requesting reconsideration. Expedited Review. If TexCare and/or HHSC becomes aware that an enrollee’s medical condition necessitates an expedited review, in accordance with 42 CFR 457.1160(b)(2), TexCare will grant a continuation of the enrollee’s current enrollment pending the expedited review. Reconsideration by the Health and Human Services Commission 1) An applicant or member must request reconsideration by HHSC in writing. 2) HHSC must complete its reconsideration of its final decision in a timely manner based upon receipt of the written request for reconsideration by HHSC. 3) The reconsideration decision must include the reasons for the decision.

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Page 68

Official source

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

Effective Date:

Approval Date: 68 Conduct of the Review Applicants and members have a right to: 1) represent themselves or have representatives of their choosing participate in the review; 2) timely review their files and other applicable information relevant to the review; and 3) participate fully in the review, whether the appeal is conducted in person, in writing, or by telephone. Disposition of the Review Timely Review. TexCare must complete its decision on the review in a timely manner and furnish a copy of the decision to the applicant or member. The review decision must: 1) state whether the initial adverse action or determination was upheld or reversed and the reasons why; and 2) explain the individual’s right to request a second reconsideration by the Health and Human Services Commission or its designee, of the initial adverse action or determination, and include instructions on requesting reconsideration. Expedited Review. If TexCare and/or HHSC becomes aware that an enrollee’s medical condition necessitates an expedited review, in accordance with 42 CFR 457.1160(b)(2), TexCare will grant a continuation of the enrollee’s current enrollment pending the expedited review. Reconsideration by the Health and Human Services Commission 1) An applicant or member must request reconsideration by HHSC in writing. 2) HHSC must complete its reconsideration of its final decision in a timely manner based upon receipt of the written request for reconsideration by HHSC. 3) The reconsideration decision must include the reasons for the decision.