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  • Dispute Resolution for Commercial and CHP Plans > Clinical Appeal - Expedited Process

    If a member or designee is not satisfied with a service or a determination that was rendered based on issues of medical necessity, an experimental or investigational use, a rare disease or (in certain instances) out-of-network services, an expedited appeal may be filed if we determine or the provider indicates that a delay would seriously jeopardize the member’s life, health or ability to attain, maintain or regain maximum function. The member or designee may request expedited review of a prior approval request or concurrent review request.

    An expedited appeal may be filed:

    • For continued or extended health care services, procedures or treatments
    • For additional services for members undergoing a course of continued treatment
    • When the health care provider believes an immediate appeal is warranted
    • When EmblemHealth honors the member’s request for an expedited review

      Expedited appeals should be accompanied by a copy of the denial letter, an explanation outlining the details of the request for a review and all documentation to support a reversal of the decision. The expedited utilization review appeal may be filed in writing or by telephone.

      Missing Information

      If EmblemHealth required information necessary to conduct an expedited appeal, EmblemHealth shall immediately notify the member and the member's health care provider by phone or fax and to identify and request the necessary information followed by written notification.

      Reviewer of Expedited Appeal Requests

      The review will be conducted by a qualified EmblemHealth medical director who was neither involved in prior determinations nor the subordinate of any person involved in the initial adverse determination. A clinical peer reviewer will be available to discuss the appeal within one business day.

      Denial of Expedited Appeal Process

      If we deny the request for expedited review because it does not meet the criteria for an expedited appeal, we will process the request through the standard appeal review time frames and will notify the appellant of this verbally and in writing.

      Failure to Render a Decision

      If we do not render a decision on the appeal within the applicable timelines, the adverse determination will be reversed automatically and the requested services or benefits will be approved.

      Expedited Appeal Not Resolved to Member's Satisfaction

      Expedited appeals not resolved to the satisfaction of the member or designee may be re-appealed through EmblemHealth's process for standard appeals described below. In the alternative, the member or designee may request an external appeal process.

      We will review the request and respond within the time frames noted in the following table:

      TABLE 21-10, CLINICAL APPEAL - EXPEDITED
      COMMERCIAL AND CHILD HEALTH PLUS PLANS

      BENEFIT PLAN(S)

      WHAT/HOW/WHERE TO FILE:

      INSTRUCTIONS

      TIME FRAMES

      ADDITIONAL RIGHTS

      Initial Member/Provider* Filing

      EmblemHealth Acknowledges Receipt

      EmblemHealth Determination Notification

      HIP Commercial,
      HIP Child Health Plus and EmblemHealth CompreHealth EPO

      Unless otherwise directed in the denial letter, write to

      EmblemHealth
      Grievance and Appeal Dept
      PO Box 2844
      New York, NY 10116-2844

      Telephone:
      1-888-447-6855

      Fax to:
      1-866-350-2168

      Member: 180 calendar days from receipt of written adverse determination.

      Provider: Pre-Service on behalf of the member: 180 calendar days from receipt of written adverse determination.

      Expedited determinations are made in less than 15 days.

      2 business days from receipt of all necessary
      information, but not to exceed 72 hours from receipt of appeal.

      May appeal using our standard appeal process.

      External appeal process.

      Additional complaints may be filed with the NYS DOH at any time by calling 1-800-206-8125.

      GHI HMO

      Unless otherwise directed in the denial
      letter, write to:

      GHI HMO
      Appeals and Complaints Dept
      PO Box 2807
      New York, NY 10117-2807

      Telephone:
      1-877-244-4466

      TDD: 1-877-208-7920

      Fax to:
      1-845-340-3435

      Member: 180 calendar days from receipt of written adverse determination.

      Provider: Pre-Service on behalf of the member 180 calendar days from receipt of written adverse determination.

      Expedited determinations are made in less than 15 days.

      2 business days from receipt of all necessary information, but not to exceed 72 hours from receipt of appeal.

      May appeal using our standard appeal process

      External appeal process.

      Additional complaints may be filed with the NYS DOH at any time by calling 1-800-206-8125.

      GHI PPO and
      EmblemHealth PPO/EPO

      Unless otherwise directed in the denial letter, write to:

      GHI or EmblemHealth
      Supervisor of Appeals
      PO Box 2809
      New York, NY 10116

      Telephone:
      1-888-906-7668

      Fax to:
      1-212-287-2754

      Member: 180 calendar days from receipt of written adverse determination.

      Provider: Pre-Service on behalf of the member: 180 calendar days from receipt of written adverse determination.

      Expedited determinations are made in less than 15 days.

      2 business days from receipt of all necessary information, but not to exceed 72 hours from receipt of appeal.

      May appeal using our standard appeal process.

      External appeal process

      *Contracted provider time frames in provider agreements will supersede time frames in this manual except in the case of regulatory requirements.

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      Glossary terms found on this page:

      An activity of EmblemHealth or its subcontractor that results in:

      • Denial or limited authorization of a service authorization request, including the type or level of service
      • Reduction, suspension or termination of a previously authorized service
      • Denial, in whole or in part, of payment for a service
      • Failure to provide services in a timely manner
      • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

      A determination by EmblemHealth or its agents that an admission, extension of stay or other health care service has been reviewed and, based on the information provided, is not medically necessary.

      Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.

      A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

      Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

      A physician who possesses a current and valid license to practice medicine or a health care professional other than a licensed physician who:

      • Where applicable possesses a current and valid nonrestricted license, certificate or registration or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body to the profession
      • Is in the same profession and the same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under review

      Initial oral or written communication from a member or their designee or provider that expresses discontent with any aspect of their care or coverage with EmblemHealth. Specifically, it is dissatisfaction with:

      • A determination made by the plan, other than a determination of medical necessity or a determination that a service is considered experimental or investigational
      • Treatment experienced through the plan, its providers or contractors
      • Any concern with the plan, its benefits, employees or providers.

      A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

      A person authorized by the insured to assist in obtaining access to, or payment to, the insured for health care services. If the insured has already received health care services and has no liability for payment of services, a designee will not be authorized for the purpose of requesting an external appeal.

      A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

      Oral or written request to review or reconsider an initial adverse determination when waiting for a standard decision could seriously harm the enrollee's life, health or their ability to regain maximum function. For pre-service expedited requests, the practitioner may act on behalf of the member. Also called a fast track appeal.

      Written request for an independent entity that has been certified by the State to conduct a review of a denial of coverage, based on lack of medical necessity or that the service requested is experimental and investigational.

      A request to change an adverse determination that was based on administrative policies, procedures or guidelines.

      A professionally licensed individual, facility or entity giving health-related care to patients. Physicians, hospitals, skilled nursing facilities, pharmacies, chiropractors, nurses, nurse-midwives, physical therapists, speech pathologist and laboratories are providers. All network providers are health care providers, but not all providers are network providers.

      An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

      Initial determination made by a utilization management agent for a denial of a service authorization request on the basis that the requested service is not medically necessary or an approval of a service authorization in an amount, duration or scope is less than requested.

      Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

      A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.

      An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

      The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

      The use of health care providers who have not contracted with the health plan to provide services. Depending on the member's contract, out-of-network services may not be covered.

      A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

      The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

      A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

      • Doctor of medicine
      • Doctor of osteopathy
      • Dentist
      • Chiropractor
      • Doctor of podiatric medicine
      • Physical therapist
      • Nurse midwife
      • Certified and registered psychologist
      • Certified and qualified social worker
      • Optometrist
      • Nurse anesthetist
      • Speech-language pathologist
      • Audiologist
      • Clinical laboratory
      • Screening center
      • General hospital
      • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

      A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

      A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. Also called Coordinated Care.

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