§457.1130. Program specific review process: Matters subject to review.
42 C.F.R. § 457.1130
Eligibility or enrollment matter. A State must ensure that an applicant or enrollee has an opportunity for review, consistent with §§ 457.1140 and 457.1150, of a—
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.
Health services matter. A State must ensure that an enrollee has an opportunity for external review of a—
Delay, denial, reduction, suspension, or termination of health services, in whole or in part, including a determination about the type or level of services; and
Failure to approve, furnish, or provide payment for health services in a timely manner.
Exception. A State is not required to provide an opportunity for review of a matter described in paragraph (a) or (b) of this section if the sole basis for the decision is a provision in the State plan or in Federal or State law requiring an automatic change in eligibility, enrollment, or a change in coverage under the health benefits package that affects all applicants or enrollees or a group of applicants or enrollees without regard to their individual circumstances.
Notes, amendments, and revision history
Source
Source: 66 FR 2687, Jan. 11, 2001, unless otherwise noted.
Authority
Authority: 42 U.S.C. 1302.
Source
Source: 65 FR 33622, May 24, 2000, unless otherwise noted.