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  • Dispute Resolution for Commercial and CHP Plans > Key Terminology

    The following descriptions provide a general overview of the terminology used with Commercial plans (including Child Health Plus).

    Adverse Determination
    A notification sent when a health care service, procedure or treatment is denied.

    A request to review any aspect of an adverse clinical determination based on medical necessity.

    A request to review an administrative process, service or quality-of-care issue that does not pertain to a determination based on claims, benefits or medical necessity.

    A request to review any aspect of an adverse benefit or claim determination that is not based on medical necessity.

    Certain disputes - whether they are appeals, complaints or grievances - may be filed as expedited or standard depending on the urgency of the patient's condition.

    Certain disputes may also be filed as pre-service or post-service depending on the timing of the determination in question.

    Managing Entities' Role in Dispute Resolution

    EmblemHealth contracts with separate managing entities to provide care for certain types of medical conditions. In these cases, the designated managing entity will determine the applicable process for filing a dispute. Any aspect of service rendered by EmblemHealth or any entity designated to perform administrative functions on our behalf is hereafter jointly referred to as "EmblemHealth."

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    Glossary terms found on this page:

    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.

    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).

    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.

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

    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 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.


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