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94 or DHCS for the first time. A first level appeal must be filed within 60 days of the date on the decision notification by vendor or state. The administrative vendor or health plan will forward first level appeals within five (5) business days of receipt to DHCS. The appeal must explain why the applicant thinks the decision was incorrect and how they want the program to resolve the issue.

Exceptions:

The administrative vendor or health plan will forward any first level appeal to DHCS if:

• The appeal includes outstanding medical bills incurred due to a disputed effective date of coverage. • The appeal is of a sensitive nature and the referral has been approved (i.e., request from legislative member).

All appeals requiring DHCS’ review will be forwarded to DHCS within 5 business days of receipt. MCAP will provide a timeline/chronology of critical events (application received, determination made or not made, letters sent to or by the applicant, earliest effective date, etc.) and identify any mistakes.

If a first level appeal is denied, the applicant will be notified of his or her right to request an administrative hearing.

c. As required in 42 CFR 457.1170, California provides enrollees the opportunity for continuation of enrollment pending the completion of review of a termination of enrollment, including a decision to disenroll for failure to pay cost sharing. Prior to disenrollment, enrollees are notified of the impending termination, the reason for such termination, and a pre-printed form in which to request continued enrollment and to provide the necessary information or explanation as to why termination should not occur. This provision of the Program was implemented in February 2003.

d. As required by 42 CFR 457.1180, California provides timely written notification to applicants and enrollees on all decisions made. In addition, as explained in Paragraphs a., and c. above, all decisions which have a negative impact on an applicant or enrollee include the reason for the determination, instructions on how to appeal the decision and request continued enrollment if the applicant or enrollee believes the decision is incorrect, and the standard and expedited timeframes for review.

e. As required by 42 CFR 457.1140(c), California provides all review decisions in writing.

f. As required by 42 CFR 457.1140(b) and 457.1160(a), California completes reviews in a