42 C.F.R. § 457.1130 Program specific review process: Matters subject to review.
Title 42 - Public Health
(a) 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— (1) Denial of eligibility; (2) Failure to make a timely determination of eligibility; and (3) Suspension or termination of enrollment, including disenrollment for failure to pay cost sharing. (b) Health services matter. A State must ensure that an enrollee has an opportunity for external review of a— (1) 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 (2) Failure to approve, furnish, or provide payment for health services in a timely manner. (c) 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.
Title 42: Public Health
PART 457—ALLOTMENTS AND GRANTS TO STATES
Subpart K—State Plan Requirements: Applicant and Enrollee Protections
§ 457.1130 Program specific review process: Matters subject to review.
