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  • Dispute Resolution for Commercial and CHP Plans > Member Dispute Resolution Procedures: Complaints and Grievances


    Appointing a Designee

    Members wishing to dispute a determination or claim denial may do so themselves or designate a person or practitioner to act on their behalf. To appoint a designee, members must submit by fax or by mail a signed HIPAA Compliant Authorization Form or a Power of Attorney form that specifies the individual as an authorized party.

    Extensions

    In certain circumstances, dispute resolution time frames may be extended if permitted by law and requested by the complainant, or if EmblemHealth believes an extension is in the best interest of the member.

    Member Complaint - First Level Process

    A member or designee may file a first level complaint when the member is dissatisfied with any aspect of an EmblemHealth-rendered service that does not pertain to a benefit or claim determination. Examples of such dissatisfaction include:

    • Dissatisfaction with treatment received from EmblemHealth, its practitioners or benefit administrators
    • Quality-of-care complaints
    • Privacy complaints regarding EmblemHealth's practices in using or disclosing protected health information
    • Alleged violation of EmblemHealth's privacy practices and/or state and federal law regarding the privacy of protected health information
    • Fraud and abuse

    Complaints should include a detailed description of the circumstances surrounding the occurrence. EmblemHealth will acknowledge receipt of the complaint and request any necessary information in writing. Complaints will be reviewed and a response will be issued in writing according to the time frames applicable to the member's benefit plan and detailed in the table on the following pages.

    TABLE 21-2, FIRST MEMBER LEVEL COMPLAINT - EXPEDITED
    COMMERCIAL AND CHILD HEALTH PLUS PLANS

    BENEFIT PLAN(S)

    WHAT/HOW/WHERE TO FILE

    TIME FRAMES

    ADDITIONAL RIGHTS

    Initial
    Member
    Filing

    EmblemHealth Acknowledges Receipt

    EmblemHealth Determination Notification

    HIP Commercial,
    HIP Child Health Plus and
    EmblemHealth CompreHealth EPO

    Write to:

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

    Telephone:
    1-800-447-8255

    60 business days from event.

    N/A

    Verbal response within 48 hours of receipt of necessary
    information.

    Written notice sent within 3 business days of determination

    May file a second level complaint,
    expedited or standard.

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

    GHI HMO

    Write to:

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

    Telephone:
    1-877-244-4466

    TTY/TDD: 711

    Fax to:
    1-845-340-3435

    90 calendar days from event.

    N/A

    Verbal response within 48 hours of receipt of necessary
    information.

    Written notice sent within 3 business days of determination.

    May file a
    second level complaint,
    expedited or standard

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

    GHI and
    EmblemHealth EPO/PPO

    Write to:

    EmblemHealth/GHI
    PO Box 2857
    New York, NY 10116

    Telephone:
    1-212-501-4444

    90 calendar days from event.

    N/A

    Verbal response within 48 hours of receipt of necessary
    information

    Written notice sent within 3 business days of determination.

    May file a
    second level complaint,
    expedited or standard.

    TABLE 21-3, FIRST LEVEL MEMBER COMPLAINT - STANDARD

    COMMERCIAL AND CHILD HEALTH PLUS PLANS

    BENEFIT PLAN(S)

    WHAT/HOW/WHERE TO FILE

    TIME FRAMES

    ADDITIONAL RIGHTS

    Initial
    Member
    Filing

    EmblemHealth Acknowledges Receipt

    EmblemHealth Determination Notification

    HIP Commercial,
    HIP Child Health Plus and EmblemHealth CompreHealth EPO

    Write to:

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

    Telephone:
    1-800-447-8255

    60 business days from event.

    15 business days from the receipt of the request

    45 calendar days from receipt of all necessary
    information.

    May file a second level complaint.

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

    GHI HMO

    Write to:

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

    Telephone:
    1-877-244-4466

    TTY/TDD: 711

    Fax to:
    1-845-340-3435

    90 calendar days from event.

    15 business days from the receipt of the request

    45 calendar days from receipt of all necessary
    information.

    May file a second level complaint.

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

    GHI and
    EmblemHealth EPO/PPO

    Write to:

    EmblemHealth/GHI
    PO Box 2857
    New York, NY 10116

    Telephone:
    1-212-501-4444

    90 calendar days from event.

    15 business days from the receipt of the request

    45 calendar days from receipt of all necessary
    information.

    May file a second level complaint.

    Member Complaint - Second Level Process

    If a member or designee is not satisfied with the resolution of a first level complaint, EmblemHealth provides a second level complaint review.

    To initiate a second level complaint, a member or designee must submit the second level complaint for review. We will respond within the timeframes noted in the tables on the following pages. Once we reach a decision, that decision is final and there are no further formal appeals or external mediation opportunities. Please refer to the grids, as in some instances, a member may have the right to complain to the NYS Department of Health.

    Second level complaints should include a detailed explanation of the request and any documentation to support the member's position.

    TABLE 21-4, SECOND LEVEL MEMBER COMPLAINT - EXPEDITED
    COMMERCIAL AND CHILD HEALTH PLUS PLANS

    BENEFIT PLAN(S)

    WHAT/HOW/WHERE TO FILE

    TIME FRAMES

    ADDITIONAL RIGHTS

    Initial
    Member Filing

    EmblemHealth Acknowledges Receipt

    EmblemHealth Determination Notification

    HIP Commercial,
    HIP Child Health Plus and
    EmblemHealth CompreHealth EPO

    Write to:

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

    Telephone:
    1-800-447-8255

    60 business days from receipt of first level
    determination.

    N/A

    2 business days from receipt of necessary
    information.

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

    GHI HMO

    Write to:

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

    Telephone:
    1-877-244-4466

    TTY/TDD: 711

    Fax to:
    1-845-340-3435

    60 business days from receipt of first level
    determination.

    N/A

    2 business days from receipt of necessary
    information.

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

    GHI and
    EmblemHealth EPO/PPO

    Write to:

    EmblemHealth/GHI
    PO Box 2857
    New York, NY 10116

    Telephone:
    1-212-501-4444

    60 business days from receipt of first level
    determination.

    N/A

    2 business days from receipt of necessary information.

    Decision is final.

    TABLE 21-5, SECOND LEVEL MEMBER COMPLAINT - STANDARD
    COMMERCIAL AND CHILD HEALTH PLUS PLANS

    BENEFIT PLAN(S)

    WHAT/HOW/WHERE TO FILE

    TIME FRAMES

    ADDITIONAL RIGHTS

    Initial Member Filing

    EmblemHealth Acknowledges Receipt

    EmblemHealth Determination Notification

    HIP Commercial,
    HIP Child Health Plus and EmblemHealth CompreHealth EPO

    Write to:

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

    Telephone:
    1-800-447-8255

    60 business days from receipt of first level
    determination.

    15 business days from receipt of the request.

    30 business days from receipt of all necessary
    information.

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

    GHI HMO

    Write to:

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

    Telephone:
    1-877-244-4466

    TTY/TDD: 711

    Fax to:
    1-845-340-3435

    60 business days from receipt of first level
    determination.

    15 business days from receipt of the request.

    30 business days from receipt of all necessary
    information.

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

    GHI and
    EmblemHealth EPO/PPO

    Write to:

    EmblemHealth/GHI
    PO Box 2857
    New York, NY 10116

    Telephone:
    1-212-501-4444

    60 business days from receipt of first level
    determination.

    15 business days from receipt of the request.

    30 business days from receipt of all necessary
    information.

    Decision is final.

    Member Grievance - First Level Process

    If a member or designee is not satisfied with any aspect of a benefit or claim determination rendered by EmblemHealth that does not pertain to a medical necessity, experimental determination or investigational determination, he/she may file a first level grievance.

    Grievances should be accompanied by a copy of the adverse determination, an explanation outlining the details of the request for a review and all documentation to support a reversal of the decision. We will acknowledge receipt of the grievance and request any necessary information in writing. Grievances will be reviewed and a response will be issued according to the time frames detailed in the tables on the following pages.

    TABLE 21-6, FIRST LEVEL MEMBER GRIEVANCE - EXPEDITED

    COMMERCIAL AND CHILD HEALTH PLUS PLANS

    BENEFIT PLAN(S)

    WHAT/HOW/WHERE TO FILE

    TIME FRAMES

    ADDITIONAL RIGHTS

    Initial
    Member
    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:
    1-800-447-8255

    180 calendar days from receipt of
    written adverse
    determination.

    N/A

    No later than 48 hours from receipt of all necessary information but not to exceed 72 hours from receipt of the grievance.

    Verbally at time of determination.

    Written notice provided no later than 48 hours from receipt of all necessary information or 72 hours from receipt of the grievance.

    May file a
    second level grievance.

    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

    TTY/TDD: 711

    Fax to:
    1-845-340-3435

    180 calendar days from receipt of written adverse
    determination.

    N/A

    No later than 48 hours from receipt of all necessary information but not to exceed 72 hours from receipt of the grievance.

    Verbally at time of determination.

    Written notice provided no later than 48 hours from receipt of all necessary information or 72 hours from receipt of the grievance.

    May file a
    second level grievance.

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

    GHI and
    EmblemHealth EPO/PPO

    Unless otherwise directed in the denial letter, write to:

    EmblemHealth/GHI
    PO Box 2857
    New York, NY 10116

    Telephone:
    1-212-501-4444

    180 calendar days from receipt of written adverse
    determination.

    N/A

    No later than 48 hours from receipt of all necessary information but not to exceed 72 hours from receipt of the grievance.

    Verbally at time of determination.

    Written notice provided no later than 48 hours from receipt of all necessary information or 72 hours from receipt of the grievance.

    May file a
    second level grievance.

    TABLE 21-7, FIRST LEVEL MEMBER GRIEVANCE - STANDARD

    FOR COMMERCIAL AND CHILD HEALTH PLUS PLANS

    BENEFIT PLAN(S)

    WHAT/HOW/WHERE TO FILE:

    INSTRUCTIONS

    TIME FRAMES

    ADDITIONAL RIGHTS

    Initial Member 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:
    1-800-447-8255

    180 calendar days from receipt of
    written adverse determination.

    Pre-Service: Acknowledgement is not required if the response is sent by the 15th calendar day of receipt.

    Post-Service: 15 calendar days from receipt of the grievance.

    Pre-Service: 15
    calendar days from receipt of the grievance.

    Post-Service: 30
    calendar days from receipt of grievance.

    May file a
    second level grievance.

    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

    TTY/TDD: 711

    Fax to:
    1-845-340-3435

    180 calendar days from receipt of
    written adverse determination.

    *15 business days from receipt of the grievance (post-service)

    *acknowledgement is not required if responded to within 15 calendar days

    Pre-Service: 15 calendar days from receipt of the grievance.

    Post-Service: 30 calendar days from receipt of grievance.

    May file a
    second level grievance

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

    GHI and EmblemHealth EPO/PPO

    Unless otherwise directed in the denial letter, write to:

    EmblemHealth/GHI
    PO Box 2857
    New York, NY 10116

    Telephone:
    1-212-501-4444

    180 calendar days from receipt of
    written adverse determination.

    *15 business days from receipt of the grievance (post-service)

    *acknowledgement is not required if responded to within 15 calendar days

    Pre-Service: 15 calendar days from receipt of the grievance.

    Post-Service: 30 calendar days from receipt of grievance.

    May file a second level grievance.

    Member Grievance - Second Level Process

    If a member or designee is not satisfied with the resolution of a first level grievance, we provide a second level grievance review.

    To initiate a second level member grievance, the member or designee must submit the second level grievance with all supporting documentation. We will review the grievance and respond within the time frames noted in the tables on the following pages.

    TABLE 21-8, SECOND LEVEL MEMBER GRIEVANCE - EXPEDITED

    COMMERCIAL AND CHILD HEALTH PLUS PLANS

    BENEFIT PLAN(S)

    WHAT/HOW/WHERE TO FILE:

    INSTRUCTIONS

    TIME FRAMES

    ADDITIONAL RIGHTS

    Initial
    Member
    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:
    1-800-447-8255

    60 business days from receipt of
    written
    grievance determination.

    N/A

    Within 2 business days of receipt of necessary information but not to exceed 72 hours.

    Verbally at time of determination. Written notice is provided no later than 2 business days from receipt of all necessary information, or 72 hours from receipt of the grievance.

    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 2844
    New York, NY 10116-2844

    Telephone:
    1-877-244-4466

    60 business days from receipt of
    written
    grievance determination.

    N/A

    Within 2 business days of receipt of necessary information but not to exceed 72 hours.

    Verbally at time of determination. Written notice is provided no later than 2 business days from receipt of all necessary information, or 72 hours from receipt of the grievance.

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

    GHI and EmblemHealth EPO/PPO

    Unless otherwise directed in the denial letter, write to:

    EmblemHealth/GHI
    PO Box 2844
    New York, NY 10116

    Telephone:
    1-212-501-4444

    60 business days from receipt of written
    grievance determination.

    -- N/A

    Within 2 business days of receipt of necessary information but not to exceed 72 hours.

    Verbally at time of determination. Written notice is provided no later than 2 business days from receipt of all necessary information, or 72 hours from receipt of the grievance.

    Decision is final

    TABLE 21-9, SECOND LEVEL MEMBER GRIEVANCE - STANDARD

    COMMERCIAL AND CHILD HEALTH PLUS PLANS

    BENEFIT PLAN(S)

    WHAT/HOW/WHERE TO FILE INSTRUCTIONS

    TIME FRAMES

    ADDITIONAL RIGHTS

    Initial
    Practitioner 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:
    1-800-447-8255

    60 business days from receipt of
    written
    grievance determination.

    Pre-Service: Acknowledgement is not required if responded to within 15 calendar days.

    Post-Service: 15 calendar days from receipt of the grievance-appeal.

    Pre-Service: 15
    calendar days from receipt of grievance-appeal.

    Post-Service: 30
    calendar days from receipt of grievance-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:

    GHI HMO
    Appeals and Complaints Dept
    PO Box 2844
    New York, NY 10116-2844

    Telephone:
    1-877-244-4466

    60 business days from receipt of
    written
    grievance determination.

    Pre-Service: Acknowledgement is not required if responded to within 15 calendar days.

    Post-Service: 15 calendar days from receipt of the grievance-appeal.

    Pre-Service: 15
    calendar days from receipt of grievance-appeal.

    Post-Service: 30
    calendar days from receipt of grievance-appeal.

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

    GHI and
    EmblemHealth EPO/PPO

    Unless otherwise directed in the denial letter, write to:

    EmblemHealth/GHI
    PO Box 2844
    New York, NY 10116-2844

    Telephone:
    1-877-842-3625

    60 business days from receipt of
    written
    grievance determination.

    Pre-Service: Acknowledgement is not required if responded to within 15 calendar days.

    Post-Service: 15 calendar days from receipt of the grievance-appeal.

    Pre-Service: 15
    calendar days from receipt of grievance-appeal.

    Post-Service: 30
    calendar days from receipt of grievance --

    Decision is final.

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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.

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    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.

    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 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.

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

    A federal act that protects people who change jobs, are self-employed or have pre-existing medical conditions. The act standardizes an approach to the continuation of health care benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those offered to employees in large group plans. The act also contains provisions to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status and protects the confidentiality of protected health information of members. Also known as the Health Insurance Portability and Accountability Act.

    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.

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    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 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.

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