Medicaid Members' Rights to a State Fair Hearing
In accordance with applicable federal and state laws and regulations, Medicaid members may request a fair hearing for adverse determinations made by EmblemHealth regarding the denial, termination, suspension or reduction of a clinical treatment or other benefit package services. A member may also seek a fair hearing for a failure by EmblemHealth to act with reasonable promptness with respect to such services. EmblemHealth must abide by and participate in New York State's Fair Hearing Process and comply with determinations made by a fair hearing officer.
Along with the right to a fair hearing for the reasons stated above, the member has a right to information on how to request a fair hearing, the rules of a fair hearing, the right to aid continuing and information on their liability for services if EmblemHealth's denial is upheld in fair hearing.
HIP members may request a fair hearing for adverse local department of social service (LDSS) determinations concerning enrollment, disenrollment and eligibility, and the denial, termination, suspension or reduction of a clinical treatment or other benefit package services by HIP or the delegate entity responsible for managing the member's medical care. For issues related to disputed services, members must have received an adverse determination either overriding a recommendation to provide services by a participating provider or confirming the decision of a participating provider to deny those services. Members who choose to request a fair hearing must do so within 60 days from the date of our initial action notice that the member previously received. The time frame to request a fair hearing is not delayed or suspended if the member pursues other appeal options.
Members may also seek a fair hearing for a failure of the Plan to comply with required notification timeframes.
Members may request a fair hearing by:
- Telephone: 1-800-342-3334
- Fax: 1-518-473-6735
- Internet: www.otda.ny.gov
New York State Office of Temporary and Disability Assistance
Office of Administrative Hearings
Managed Care Hearing Unit
PO Box 22023
Albany, NY 12201
Members have a right to:
- Designate an individual to represent them in fair hearing proceedings. Members may also be able to get legal help by contacting their local Legal Aid Society or advocate group.
- Free copies of the Evidence Package that HIP will give to the fair hearing officer. We will send members a copy of the Evidence Package at the same time we send it to the fair hearing officer.
- Free copies of other documents from the member's file that the member may want for the fair hearing.
To ask for copies of documents, the member may call 1-800-447-8255 or write to HIP at the address on the top of the front page of the Fair Hearing Request form. Members should ask for these documents before the date of the fair hearing. Usually, they will be sent within three working days of when the request was received.
If the services a member is receiving are scheduled to end, the member can choose to ask to continue the services ordered by his/her doctor pending the fair hearing decision. If the fair hearing officer grants Aid Continuing, the member will continue to receive services until the fair hearing determination is made. However, if the fair hearing is decided against the member, the member may have to pay the cost for the services received while waiting for the decision.
Fair hearing officer determinations are final and supersede New York State External Review determinations.
EmblemHealth and its contractors will be required to continue or restore the provision of services that are the subject of the fair hearing if so ordered by the New York State Office of Administrative Hearings (OAH) under the following circumstances:
- When EmblemHealth has or is seeking to reduce, suspend or terminate a treatment or benefit package service currently being provided.
- When a member has filed a timely request for a fair hearing with OAH.
- When there is a valid order for the treatment or service from a participating practitioner.
EmblemHealth will provide aid continuing until one of the following occurs (whichever comes first):
- The matter has been resolved to the member's satisfaction.
- The administrative process is complete and there is a determination from OAH that the member is not entitled to receive the service.
- The member withdraws the request for aid continuing and/or the fair hearing in writing.
- The treatment or service originally ordered by the practitioner has been completed.
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 legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
A business entity that performs delegated functions on behalf of the insurer or managed care organization.
An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.
A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.
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.
A city or county social services district as constituted by Section 61 of the New York State Social Services Law (SSL). Also called a Local Department of Social Services.
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.
Professional services rendered by a physician for the treatment or diagnosis of an illness or injury.
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 physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A participating provider is a member of the EmblemHealth network of providers applicable to the member's certificate. Therefore, they are more commonly referred to as network providers. Payment is made directly to a participating provider. Please consult the EmblemHealth Directory or go online to search for participating providers.
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
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- 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.