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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

76 Approval Date: _____________/06

8. The MCO shall provide to the external review organization all information necessary for any enrollee appeal within the time frame established by the Department.

9. All applicants/enrollees shall have the right to have personal and medical information and records maintained as confidential.

10. 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, whether the review is in person or in writing, 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 reduction or termination of services or payment for services.

11. Unless an expedited review decision is mandated, the external review organization shall complete the external review process and issue a decision within ninety (90) calendar days of the date an enrollee requests an internal review. If the enrollee’s physician or health plan determines that operating under the standard time frame could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function, then the external review organization must complete the external review process and issue a decision within seventy-two (72) hours of the time an enrollee requests external review.

12. The MCO shall comply with the external review decision. The external review organization's decision in these matters shall be final and shall not be subject to appeal by the MCO.

13. The external review organization’s decision must be in writing and shall include but not be limited to: