Appeals

Standard Reconsiderations

A reconsideration is a request from a member, their designee or non-contracted provider to reverse or modify an initial determination to deny, reduce or discontinue services or the denial of payment for medical care. The time frame for filing a reconsideration is 60 calendar days from the date of the notice of the adverse determination. This may be extended if the member shows good cause (this must be requested in writing and give the reason that it was not filed timely).

For reconsiderations for services that have not been rendered yet (pre-service reconsiderations), EmblemHealth must make its reconsidered determination as quickly as the member’s health condition requires, but no later than 30 calendar days from the date we receive the request for a standard reconsideration. The time frame will be extended by up to 14 calendar days by EmblemHealth if the member requests the extension, or also may be extended by up to 14 calendar days if EmblemHealth justifies a need for additional information and documents how the delay is in the best interest of the member. When EmblemHealth extends the time frame, it must notify the member in writing of the reasons for the delay, and inform the member of the right to file an expedited grievance if he or she disagrees with EmblemHealth’s decision to grant itself an extension. For reconsiderations for a request for reimbursement (services that have already been received and you have paid for), EmblemHealth must make its reconsidered determination no later than 60 calendar days from the date we receive the request.

Standard reconsiderations can be filed orally or in writing as follows:

EmblemHealth Medicare HMO
Attn: Grievance & Appeals
PO Box 2807  
New York, NY 10116-2807
Phone: 1-877-344-7364
TTY/TDD: 711
Fax: 1-212-510-5320

Standard Part D Coverage Redeterminations

A coverage redetermination is a request to have an unfavorable coverage determination reviewed or reconsidered for Part D. This includes decisions made by the plan about coverage of a Part D benefit or what amount the plan will pay for a drug. A member, their authorized representative, or the provider acting on the member’s behalf must file their request for a redetermination within 60 calendar days of the date of the notice of the coverage determination. This may be extended if the member shows good cause (this must be requested in writing and give the reason that it was not filed timely).

For a standard redetermination, EmblemHealth will make the determination and give notice within 7 calendar days of receiving the request. If we approve a request for coverage, we must authorize the drug as quickly as your health requires, but no later than 7 calendar days after we receive your request for redetermination. If we approve your request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your redetermination request.

Standard coverage redetermination requests can be filed orally or in writing as follows:

EmblemHealth Medicare HMO
Attn: Grievance & Appeals
PO Box 2807  
New York, NY 10116-2807
Phone: 1-877-344-7364
TTY/TDD: 711
Fax: 1-212-510-5320
EmblemHealth Medicare PDP
Attn: Grievance & Appeals
PO Box 2807  
New York, NY 10116-2807
Phone: 1-877-444-7241
TTY/TDD: 711
Fax: 1-212-510-5320

Medicare Prescription Drug Coverage Redetermination Request Form



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