Impartial Eligibility Review

Your Child’s Eligibility, Coverage and Payments

Eligibility | Coverage | Payment | Termination of Coverage | Impartial Eligibility Review

Impartial Eligibility Review

An impartial eligibility review may be requested when:

An applicant is denied coverage;
An enrollee’s coverage is to be terminated; or
An enrollee’s coverage is to change from Free CHIP to Low Cost CHIP.

The Review
The review is an informal process and is not an administrative hearing. The primary objectives of the review are to, where possible, facilitate resolution of the matter at issue and to enroll the child, when appropriate.

A review officer will review the application/renewal documents and verification and the letter of request prior to the conference call (review interview) in order to become familiar with the case circumstances. You or your representative may submit additional documents that may have an impact on the outcome. The reviewer may ask for additional documentation as needed.

The reviewer will consider the eligibility factors, the documents provided and the relevant eligibility requirements. A written decision in the form of a letter will be prepared and sent to you and your representative (if appropriate) and to the Caring Foundation. The Foundation will implement the decision of the review officer upon receipt of the letter.

Continuation of Coverage for Enrollees/Free CHIP
Coverage of an enrolled child in Free CHIP should continue uninterrupted pending the outcome of the eligibility review. In the event that a child is terminated prior to the timely receipt of a request for review, coverage will be reinstated retroactively to the date of termination.

Continuation of Coverage for Enrollees/Low Cost CHIP
Coverage of a child enrolled in Low Cost CHIP should continue uninterrupted pending the outcome of the eligibility review if you elect to continue paying the monthly premium until the review process is completed.

When a request for review is received for an enrollee in Low Cost CHIP, you will be offered the option of paying the premium in order for coverage to continue pending the outcome of the review.

If you elect to continue paying the premium, coverage will continue.
If you elect not to pay, coverage will not continue.

Filing a Request for an Impartial Review
You may request a review for your child within 30 days of the date of the notice of ineligibility, termination or change from free to low cost coverage. A request for a review should be sent to:

Pennsylvania Insurance Department
CHIP Eligibility Review Unit
333 Market Street, 2nd Floor Landing
Harrisburg, PA 17120
FAX: 717-705-1643

A request for an impartial review must:

Be filed in written or printed form (e.g. letter, e-mail, FAX);
Be post marked or received within 30 calendar days of the date of the notice of ineligibility, termination or change from free to low cost coverage;
Contain the reason for the request along with a copy of the denial, termination or transfer letter from the Caring Foundation; and
Be signed by the parent or guardian.

If you request assistance in filing a written request, the Caring Foundation or Pennsylvania Insurance Department will help in whatever way is determined necessary. A sample letter for filing a request for review may be obtained by calling the Foundation at 1-800-464-5437.

NOTE:

You may withdraw your request for an impartial review at any time.

When a Request for an Impartial Review is Received

Coverage should continue or be reinstated until the review process has been concluded;
The Insurance Department will schedule a review interview. (The review will be held by telephone unless you request a face-to-face review);
The Foundation will be informed that the interview has been scheduled;
You will be informed in writing of the:

Date, time and location of the interview
Right to have a representative during the interview
Right to have appropriate interpretative service available during the interview if needed
Opportunity for continuation of coverage for an enrolled child so long as premium payments are made (when appropriate);

The Caring Foundation will:

Conduct a management review of the decision of ineligibility within two working days of the date of notification by the Insurance Department to assure that the decision made regarding ineligibility was appropriate; and
Inform the review officer of the results of the management review
If the management review determines that the eligibility decision was not appropriate, the Caring Foundation will:

Inform you and the review officer in writing that an error occurred and the child is eligible;
Enroll the applicant child retroactively to the date that the child should have been enrolled; and
Re-enroll an enrollee who has been terminated retroactively to the date the child was terminated.

NOTE:

Re-enrollment of a child terminated from Low Cost CHIP is completely contingent upon the receipt of the applicable premium(s).

The Insurance Department will:

Designate a review officer to conduct the eligibility review;
Issue a written decision after the review has been completed; or
Send confirmation that a request for a review has been withdrawn, if appropriate. Withdrawal of a request may occur if the Caring Foundation, applicant or enrollee informs the Department that the request for review has been withdrawn for any reason. Example: Caring Foundation has resolved the matter at issue prior to the date of the scheduled review