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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 191. State Plan for the Children with Special Health Care Needs Program
11/23/2024

12VAC5-191-80. Appeal process.

A. An applicant for or client in receipt of services or assistance, as defined in this plan, may appeal the following actions:

1. Denial of services or assistance.

2. Termination of services or assistance.

3. Adverse determination regarding financial eligibility.

There are no further rights of appeal except as set forth in this section. Applicants or clients have no right of appeal of a denial of services or assistance because of a lack of funds.

B. The applicant or client has the right to receive a written statement of the reasons for denial and be informed in writing of the appeal process, including time limits.

C. If a client already receiving services or assistance is denied those services or assistance, a written notice of termination including the reason of denial shall be given 30 days in advance of discontinuing services.

D. First level of appeal: An individual or his representative may make a written or oral appeal to the employee designated to be responsible for the administration of the different programs (the Care Connection for Children Program Director, Administrative Director for the Child Development Services, Bleeding Disorders Program Coordinator, or Sickle Cell Program Manager) within 30 days of the denial of service. The respective program director, administrative director, program coordinator, or program manager shall review and make a written decision to the individual or his representative within 15 days from the date of receipt of the appeal.

E. Second level of appeal: If the individual is not satisfied with the decision provided at the first level of appeal, the individual may appeal the decision in writing to the Director of the Children with Special Health Care Needs Program within 30 days of the denial from the individual program.

F. Upon receipt of the appeal, the director shall review and make written recommendations to the commissioner, or the commissioner's designee, within 15 days. The director shall consider all written information and may confer, as deemed necessary, with the department's adjudication officer or other relevant experts.

G. Within 45 days following the date on which an appeal is filed, the commissioner, or commissioner's designee, shall make a final decision.

Statutory Authority

§§ 32.1-12 and 32.1-77 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 23, Issue 21, eff. July 25, 2007; amended, Virginia Register Volume 30, Issue 7, eff. January 24, 2014.

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