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STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 11-1

Effective Date: 07/01/05

74 Approval Date: _____________/06 6. All applicants/enrollees shall have the right to have personal and medical information and records maintained as confidential.

7. All applicants/enrollees shall have an opportunity to:

a) Represent themselves or have representation of their choosing during the review process;

b) Timely review their files and other applicable information relevant to review of the decision;

c) Fully participate in the review process, including an opportunity to present supplemental information during the review process; and

d) Receive continued coverage if the enrollee requests a review prior to the effective date of the suspension or termination of the enrollment.

8. If an expedited review decision is not mandated, a request for review shall result in a written final decision within 90 calendar days of receipt of the request for review unless the applicant, enrollee, or authorized representative requests or causes a delay. An expedited review decision will be mandated whenever the State receives, from the managed care organization or the primary health provider, information indicating that taking the time for a standard resolution of the review request could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function. If an expedited review decision is mandated, then a request for review shall result in a written final decision within 3 business days after the State receives, from the managed care organization or the primary health provider, the case record and information indicating that taking the time for a standard resolution of the review request could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function, unless the applicant, enrollee, or authorized representative requests or causes a delay.

Health Services Matters

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

For reviews involving health services matters for FAMIS enrollees receiving services through Managed Care Organizations (MCOs), the following procedures shall apply.

1. The MCO shall provide a written notification within 10 days after a decision is made and provide the opportunity for external review whenever an enrollee’s request for covered services is delayed, denied, reduced, suspended, or terminated, in whole or in part including a determination