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  • Dispute Resolution for Medicaid Managed Care Plans > Member Complaint Process

    A member, member's designee or practitioner acting on a member's behalf may file a complaint when the member is dissatisfied with any aspect of service rendered by EmblemHealth that does not pertain to an action. 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 within the time frames applicable to the member's benefit plan as detailed in the table below.

    Table 22-4: Expedited Complaint Procedures for Members

    TABLE 22-4, COMPLAINT - EXPEDITED
    MEMBER, MEMBER DESIGNEE OR PRACTITIONER FILING ON MEMBER'S BEHALF
    MEDICAID MANAGED CARE

    BENEFIT PLAN(S)

    WHAT/HOW/WHERE TO FILE INSTRUCTIONS

    TIME FRAMES

    ADDITIONAL RIGHTS

    Initial
    Member
    Filing

    EmblemHealth Acknowledges Receipt

    EmblemHealth Determination Notification

    Medicaid*

    Write to:

    EmblemHealth
    Grievance and Appeal Dept.
    P.O. Box 2844
    New York, NY 10116-2844

    Telephone:
    1-800-447-8255

    TTY/TDD: 711

    Within 90 calendar days from event

    Within 15 business days from receipt

    Within 48 hours from receipt of all necessary information and no later than 7 days after receipt of the complaint

    May file a complaint appeal, expedited or standard

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

    *Includes retired Family Health Plus plan

    Table 22-5: Standard Complaint Procedures for Members

    TABLE 22-5, COMPLAINT - STANDARD
    MEMBER, MEMBER DESIGNEE OR PRACTITIONER FILING ON MEMBER'S BEHALF
    MEDICAID MANAGED CARE

    BENEFIT PLAN(S)

    WHAT/HOW/WHERE TO FILE INSTRUCTIONS

    TIME FRAMES

    ADDITIONAL RIGHTS

    Initial
    Member
    Filing

    EmblemHealth Acknowledges Receipt

    EmblemHealth Determination Notification

    Medicaid*

    Write to:

    EmblemHealth
    Grievance and Appeal Dept.
    P.O. Box 2844
    New York, NY 10116-2844

    Telephone:
    1-800-447-8255

    TTY/TDD: 711

    90 calendar days

    Within 15 business days from receipt

    Within 45 calendar days from receipt of all necessary info, but not to exceed 60 calendar days from receipt of the complaint

    May file a complaint appeal, expedited or standard

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

    *Includes retired Family Health Plus plan

    Member Complaint Appeal Process

    If a member, member's designee or practitioner acting on behalf of a member is not satisfied with the resolution of a complaint, EmblemHealth provides a complaint appeal process.

    To initiate a complaint appeal, a member, designee or practitioner must make the request in writing. EmblemHealth will respond within the time frames noted in the tables below. Once we reach a decision, that decision is final and there are no further internal appeals.

    Complaint appeals should include a detailed explanation of the request and any documentation to support the member's position.

    Complaint appeals filed verbally must be followed up with a written, signed appeal.

    Table 22-6: Expedited Complaint Appeals Process for Members

    TABLE 22-6, COMPLAINT APPEAL - EXPEDITED
    MEMBER, MEMBER DESIGNEE OR PRACTITIONER FILING ON MEMBER'S BEHALF
    MEDICAID MANAGED CARE

    BENEFIT PLAN(S)

    WHAT/HOW/WHERE TO FILE: INSTRUCTIONS

    TIME FRAMES

    ADDITIONAL RIGHTS

    Initial
    Member
    Filing

    EmblemHealth Acknowledges Receipt

    EmblemHealth Determination Notification

    Medicaid*

    Write to:

    EmblemHealth
    Grievance and Appeal Dept.
    P.O. Box 2844
    New York, NY 10116-2844

    Telephone:
    1-800-447-8255

    TTY/TDD: 711

    Within 60 business days from receipt of complaint determination

    Within 15 business days from receipt

    Within 2 business days from receipt of necessary information

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

    *includes retired Family Health Plus plan

    Table 22-7: Standard Complaint Appeals Process for Members

    TABLE 22-7, COMPLAINT APPEAL - STANDARD
    MEMBER, MEMBER DESIGNEE OR PRACTITIONER FILING ON MEMBER'S BEHALF
    MEDICAID MANAGED CARE

    BENEFIT PLAN(S)

    WHAT/HOW/WHERE TO FILE: INSTRUCTIONS

    TIME FRAMES

    ADDITIONAL RIGHTS

    Initial Member Filing

    EmblemHealth Acknowledges Receipt

    EmblemHealth Determination Notification

    Medicaid*

    Write to:

    EmblemHealth
    Grievance and Appeal Dept.
    P.O. Box 2844
    New York, NY 10116-2844

    Telephone:
    1-800-447-8255

    TTY/TDD: 711

    Within 60 business days from receipt of complaint determination

    Within 15 business days from receipt

    Within 30 business days from receipt of all necessary information

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

    *Includes retired Family Health Plus plan

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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

    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.

    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 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.

    Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    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 state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called the New York State Department of Health.

    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.

    New York State Department of Health. This agency provides information for consumers, doctors, researchers and health care providers.

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