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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

75 Approval Date: _____________/06 about the type or level of services; or whenever there has been the failure to approve, furnish or provide payment for health services in a timely manner.

2. Written notification must include the reasons for the determination, an explanation of rights to request a review and how to request a review, and the standard and expedited time frames for review. In addition, it shall inform the enrollee about his or her opportunity to file a grievance or a request for review with the MCO, and include the phone number and name of the contact person at the MCO’s office.

3. The MCO shall comply with the Department’s hearing process, no more or less, and in the same manner as is required for all other FAMIS evidentiary hearings.

4. The MCO shall have written policies and procedures which describe the informal and formal grievance and review process and how it operates, and the process must be in compliance with federal and State regulations. The procedures must provide for prompt resolution of the issue and involve the participation of individuals with the authority to require corrective action.

5. A review shall not be granted if the sole basis for the adverse determination is a state or federal provision requiring an automatic change that affects all applicants or enrollees or a group of applicants or enrollees without regard to their individual circumstances.

6. The MCO shall offer an internal grievance review procedure. The MCO shall issue grievance decisions within fourteen (14) days from the date of initial receipt of the grievance and after all pertinent information has been received. The decision must be in writing and shall include but not be limited to:

a. The decision reached by the MCO;

b. The reasons for the decision;

c. The policies or procedures which provide the basis for the decision; and

d. A clear explanation of further review rights and the time frame for filing a request for review.

7. The enrollee may request an external review of any formal grievance decision by the MCO. An external review organization shall manage the external review procedure. The external review organization provides an independent external review, because the external review organization is the State or a contractor other than the contractor responsible for the matter subject to external review. If an enrollee wishes to file an appeal with the external review organization, the appeal must be filed within 30 days of the enrollee’s receipt of notice of the final decision from the MCO.