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

    If a member or designee or provider is not satisfied with a service or a determination that was rendered based on issues of medical necessity, an experimental or investigational use, a clinical trial, a rare disease or (in certain instances) out-of-network services, an appeal may be filed. The standard Clinical Appeal may be filed in writing or by telephone.

    Missing Information

    If we require information necessary to conduct a standard internal appeal, we will notify the member and the member's health care provider, in writing, within 15 calendar days of receipt of the appeal (as noted in the tables below), to identify and request the necessary information. In the event that only a portion of such necessary information is received, we shall request the missing information, in writing, within five business days of receipt of the partial information.

    Reviewer of Standard 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.

    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.

    Standard Appeal Not Resolved to Members Satisfaction

    Member or designee may request an External Appeal as described in this chapter.

    Procedures for initiating a standard appeal are outlined in the tables on the
    following pages:

    TABLE 21-11, APPEAL - STANDARD

    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

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

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

    For Payment: 45 calendar days from receipt of written adverse determination.

    15 calendar days from receipt of the appeal

    HMO: 30 calendar days from receipt for pre-service requests

    60 calendar days from receipt of request for post service requests

    PPO/EPO: 30 calendar days for all requests

    Both member and provider notified within 2 business days of determination but not to exceed determination timeframe.

    External Appeal

    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:

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

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

    For Payment: 45 calendar days from receipt of written adverse determination.

    15 calendar days from receipt of the appeal

    30 calendar days from receipt for pre-service requests

    60 calendar days from receipt of request for post service requests

    Both member and provider notified within 2 business days of determination but not to exceed determination timeframe..

    External Appeal

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

    For Payment: 45 calendar days from receipt of written adverse determination.

    15 calendar days from receipt of appeal

    30 calendar days

    Both member and provider notified within 2 business days of determination but not to exceed determination timeframe.

    External appeal

    *Contracted provider time frames in provider agreements will supersede time frames in this manual.

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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.

    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 type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    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.

    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.

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