If you, your representative or your prescriber feel the standard time frame for an appeal (reconsideration or a coverage redetermination) could seriously risk the member’s life, health, or ability to get back maximum function, you can request an expedited appeal.
If the request for an expedited reconsideration is made or supported by a physician, EmblemHealth must grant the expedited reconsideration request if the physician states that the life or health of the member, or the member’s ability to regain maximum function could be seriously jeopardized by applying the standard time frame in the processing of the reconsideration request. For a member request not supported by a physician, EmblemHealth must determine if the life or health of the member, or the member’s ability to regain maximum function, could be seriously jeopardized by applying the standard time frame in the processing of the reconsideration request.
If EmblemHealth denies a request for a reconsideration to be expedited, it must transfer the request to the standard reconsideration process and then make its determination as quickly as the member’s health condition requires, but no later than 30 calendar days from the date EmblemHealth received the request for expedited reconsideration. EmblemHealth must also provide the member with prompt oral notice of the denial of the request for reconsideration, the member’s rights. We also must mail to the member within three calendar days of the oral notification, a written letter that explains that we will transfer and process the request using the 30-day time frame for standard reconsiderations, the right to file an expedited grievance if he or she disagrees with the organization’s decision not to expedite the reconsideration, and the right to resubmit a request for an expedited reconsideration. It will also state that if the member gets any physician’s support showing that applying the standard time frame for making a determination could seriously jeopardize the member’s life, health or ability to regain maximum function, the request will be expedited automatically; and provide instructions about the grievance process and its time frames.
If EmblemHealth approves a request for an expedited reconsideration, then it must complete the expedited reconsideration and give the member (and the physician involved, as appropriate) notice of its reconsideration as quickly as the member’s health condition requires, but no later than 72 hours after receiving the request. While EmblemHealth may notify the member orally or in writing, the member must be notified within the 72 hour time frame. If EmblemHealth first notifies the member orally of a completely favorable expedited reconsideration, it must mail written confirmation to the member within three calendar days. When the reconsideration is adverse the plan must mail written confirmation of its reconsideration within three calendar days after providing oral notification, if applicable. The 72-hour time frame must be extended by up to 14 calendar days if the member requests the extension. The time frame also may be extended by up to 14 calendar days if EmblemHealth finds a need for additional information and documents how the extension is in the interest of the member. When EmblemHealth extends the time frame, it must notify the member in writing of the reasons for the extension, and inform the member of the right to file an expedited grievance if he or she disagrees with EmblemHealth’s decision to grant an extension. EmblemHealth must notify the member of its determination as quickly as the member’s health condition requires, but no later than the last day of the extension.
Expedited Part D Coverage Redeterminations
For expedited redeterminations, a member or their prescribing doctor or other physician may make an oral or written request for coverage. EmblemHealth will quickly decide whether to speed up the request. Note that expedited redeterminations are not allowed for payment requests.
If the request to expedite a coverage redetermination is granted, EmblemHealth will make the determination and give notice within 72 hours of receiving the request. If more medical information is needed, the member and prescribing doctor or other physician will be told immediately.
If the request for an expedited redetermination is denied, EmblemHealth will make the determination within seven days of the request and give prompt oral notice of the denial to speed up the redetermination request. The denial will explain the standard process, tell the member of the right to file an expedited grievance, tell the member of the right to resubmit the request with the physician’s supporting documentation and give instructions about EmblemHealth’s grievance process and its time frames. We will also send a written notice within three calendar days after oral notice of the denial.
Expedited appeals can be requested in writing via fax to the appeals addresses below or by calling:
EmblemHealth Medicare HMO:
EmblemHealth Medicare PDP:|