Grievances

A grievance is any complaint other than one that involves a coverage determination. A grievance can be about administrative issues, such as EmblemHealth staff or doctors’ attitudes and/or their interactions with members. In addition, grievances may include complaints about the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. For example, dissatisfaction with wait times when filling a prescription or the cleanliness or condition of a network pharmacy. You or your representative must file a grievance no later than 60 days after the event or incident that caused the grievance. If a request to have a coverage decision, coverage determination, reconsideration or coverage re-determination expedited is denied, you can file an expedited grievance.

All grievances 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 PPO
Attn: Grievance & Appeals
PO Box 2807  
New York, NY 10116-2807
Phone: 1-866-557-7300
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

Grievances submitted orally may be answered either orally or in writing unless you ask for a written response. All grievances about quality of care, no matter how the grievance is filed, will be answered in writing. EmblemHealth will tell you its finding based upon your health status, but no later than 30 days after the date EmblemHealth gets the grievance. This time period may be extended by up to 14 days if you ask for such an extension or EmblemHealth can prove the need. If EmblemHealth extends the time frame, you will be told immediately. Expedited grievances will be answered within 24 hours.



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