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93 the CHIP Program and CCHIP.

a. As required in 42 CFR 457.1130(a), California provides applicants and enrollees the opportunity to review eligibility and enrollment issues such as denial of eligibility; failure to make a timely determination of eligibility; and suspension or termination of enrollment, including disenrollment for failure to pay cost sharing. These eligibility and enrollment issues are specifically included in the CHIP program regulations, and notification letters to applicants and enrollees. All decisions are provided in writing and all decisions which have a negative impact on an applicant or enrollee include instructions on how to appeal the decision if the applicant or enrollee believes the decision is incorrect.

b. For purposes of implementing 42 CFR 457.1170 California has determined that the first level appeal review conducted by the Title XXI Unit within DHCS meets the core requirements as defined in 42 CFR 457.1150(a) as an impartial review. This unit operates separately from the administrative vendor or health plan and the functions involving an eligibility determination. During an appeal, the information is received from the enrollee regarding the eligibility appeal, and the Title XXI unit evaluates the appeal based on specific criteria.

An applicant may file an appeal if s/he is dissatisfied with any action or failure to act, which has occurred in connection with a participating health plan’s coverage the applicant’s remedy shall be to file an appeal with DHCS, with the Title XXI unit evaluating the appeal. An applicant may also file an appeal if s/he believes eligibility effective date of coverage, enrollment decision, disenrollment decision, or plan transfer request decision was made in violation of the program rules. An applicant may designate an authorized representative to file the appeal and inquire about the status of the appeal.

The applicant must file a written appeal within 60 calendar days from the date of the written notice of the decision. The appeal is forwarded to DHCS within five (5) business days of receipt and will send the applicant a letter with this information.

Special handling cases i.e. cases that require the State’s attention, will be forwarded to DHCS (including copies of all documentation and correspondence) within five (5) business days.

If an appeal is incomplete or does not concern at least one of the three issues listed above or is received beyond the specified timeframe (i.e., 60 days), the applicant is not entitled to a full appeal, and the administrative vendor will review the request and process as correspondence.

First level appeals are written appeals received by the health plan, administrative vendor,