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

STATE: Virginia Page 12-1

Effective Date: 07/01/05

77 Approval Date: _____________/06 a. The decision reached by the external review organization;

b. The reasons for the decision;

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

For reviews involving health services matters for FAMIS enrollees receiving services through fee-for- service, the following procedures shall apply.

1. The State or its contractor 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 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.

3. 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.

4. The external review must be conducted by the State or a contractor other than the contractor responsible for the matter subject to external review.

5. If an enrollee wishes to request an external review, the request must be filed within 30 days of the enrollee’s receipt of notice of the final decision from the State or its contractor.

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, whether the review is in person or in writing, including an opportunity to present supplemental information during the review process; and