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  • Dispute Resolution for Commercial and CHP Plans > Facility Dispute Resolution Procedures


    Alternative Dispute Resolution

    An Article 28 facility may agree to an alternative dispute resolution in lieu of an external appeal. The alternative dispute process does not affect a member's external appeal rights or the member's right to establish the provider as their designee.

    Retrospective Utilization Review Requests

    If an EmblemHealth-contracted facility fails to follow prior approval and/or emergency admittance procedures, payments for such services may be denied and the facility, EmblemHealth or its managing entity may initiate a retrospective utilization review (RUR).

    • For Denials Based on "No Prior Approval"
      If the facility fails to obtain prior approval, payment will be denied for "no prior approval." The remittance statement will include information regarding the facility's right to request a retrospective utilization review for medical necessity. See the Care Management chapter.

      If the facility fails to request a retrospective utilization review and submit the medical record within 45 days of receipt of the remittance statement, the claim denial will be upheld and the facility will have no further appeal rights.

      If EmblemHealth or the managing entity fails to render and communicate a decision to the facility within 30 days of receipt of all information, the case will be deemed automatically denied and the facility will have the right to appeal the decision.
    • For Denials Based on "No E.R. Notification"
      If the facility admits a patient through the emergency room without notifying EmblemHealth or the managing entity and submits a claim for services rendered, EmblemHealth will request medical records to initiate a retrospective utilization review for medical necessity.

      If the facility fails to submit the medical record within the time frame, the facility will receive an adverse determination stating inability to establish medical necessity based on no information received. The facility will then have the opportunity to file a facility clinical appeal.

      For Facility Retrospective Utilization Review requests for outpatient PT/OT Services managed by Palladian, please follow the process in the PT/OT section.
    TABLE 21-12, FACILITY RETROSPECTIVE REVIEW REQUEST
    FOR DENIALS BASED ON "NO PRIOR APPROVAL"
    FOR DENIALS BASED ON "NO E.R. NOTIFICATION"

    BENEFIT PLAN(S)

    WHAT/HOW/WHERE TO FILE INSTRUCTIONS

    TIME FRAMES

    ADDITIONAL RIGHTS

    Initial Facility Filing

    EmblemHealth Acknowledges Receipt

    EmblemHealth Determination Notification

    All HIP** 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:
    1-800-447-8255

    45 days from the claim denial, unless specified otherwise by your contract with HIP.

    15 calendar days from receipt of necessary information.

    Determination is made within 30 days from receipt of request for retrospective utilization review.

    May file a facility clinical appeal.

    GHI HMO**

    See Member Appeal.





    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: 45 calendar days from receipt of written adverse determination.

    15 calendar days from receipt of necessary information.

    60 calendar days from receipt.

    (30 days for PPO accounts)

    Both member and provider notified within 2 business days of determination.


    External appeal

    * EmblemHealth does not send acknowledgement letters for "No E.R. Notification" retrospective review requests.

    ** HIP, GHI HMO and GHI PPO request medical records within 30 days of receipt of the claim and wait 45 to 60 days from the date of the request before sending out a denial for lack of information.

    Facility Clinical Appeals

    If an EmblemHealth-contracted facility is not satisfied with a claim determination regarding denial of payment for inpatient services based on medical necessity, the facility may file a facility clinical appeal.

    EmblemHealth provides one internal level of appeal for facilities. Federal Accounts do not have external appeal rights. Effective 1/1/2010, in cases where the initial adverse determination was made retrospectively or concurrently, the facility has the additional right to file a New York State External Appeal.

    EmblemHealth handles all facility clinical appeals, except in the following situations, where the managing entity handles the appeal:

    • If the managing entity has a direct contract with the facility.
    • The managing entity has denied the case based on medical information.
    • The managing entity has denied the case for "no information."

    EmblemHealth or the managing entity will render a decision within 30 days of receipt of the appeal request (for PPO accounts) or 60 days of receipt of the appeal request for all others.

    • For Members Already Discharged
      If the facility provides additional information after the denial is issued and after the member is already discharged, no reconsideration review will  be performed. However, the facility may exercise its right to a clinical appeal.
    • The appeal request must be filed within 45 days of the initial adverse determination or as stated in the facility contract. If the appeal request is received outside of this time frame, the original denial will be upheld and there will be no further appeal rights. Facilities are not permitted to balance bill members for such denials.
    • For Denials Based on "No Information"
      If the facility fails to provide any clinical information to establish medical necessity for an admission or procedure, the claim will be denied based on "no information" and the facility may file a clinical appeal.
    TABLE 21-13, FACILITY CLINICAL APPEAL
    FOR DENIALS BASED ON "NO INFORMATION"
    WHEN MEMBERS ARE ALREADY DISCHARGED

    BENEFIT PLAN(S)

    WHAT/HOW/WHERE TO FILE INSTRUCTIONS

    TIME FRAMES

    ADDITIONAL RIGHTS

    Initial Facility Filing

    EmblemHealth Acknowledges Receipt

    EmblemHealth Determination Notification

    All HIP 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:
    1-800-447-8255

    45 calendar days from receipt of written adverse determination.

    15 calendar days from receipt of necessary information

    For members already discharged or "no information" denial:

    5 business days from determination.

    For no E.R. notification:

    Within 2 business days of determination.

    60 calendar days.

    (30 days for PPO accounts)

    Both member and provider notified within 2 business days of
    determination.


    GHI HMO

    For members already discharged:
    This process does not exist for these plans. Please file a member appeal.

    For "no information" denial or no E.R.
    notification:
    This process does not exist for these plans. Please file a dispute of this type as a practitioner grievance.





    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: 45 calendar days from the claim denial, unless specified otherwise by your contract with HIP.

    15 calendar days from receipt of
    necessary information.

    60 calendar days from receipt .

    (30 days for PPO accounts)

    Both member and
    provider notified within 2 business days of
    determination.

    External appeal

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    Glossary terms found on this page:

    Formal acceptance as an inpatient by an institution, hospital or health care facility.

    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.

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    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.

    Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

    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 hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

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

    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.

    Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

    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.

    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.

    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 request for inpatient review, made while the member is still in the facility, of a case that was denied on the basis of medical necessity.

    A review done after services are completed (usually as part of a claim or appeal) that ensures the care given was medically necessary.

    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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