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  • Dispute Resolution for Medicaid Managed Care Plans > Notification Methods and Time Frames

    The failure of EmblemHealth to make a utilization review (UR) determination within the time periods prescribed in this section is deemed to be an adverse determination subject to appeal. EmblemHealth must send notice of denial on the date that the utilization review's time frames expire.

    For Prior Approval and Concurrent Review Requests

    EmblemHealth must make a decision and notify member and provider, by phone and in writing as fast as the member's condition requires for both prior approval and concurrent review requests. In addition, for prior approval requests the decision must be made: (1) within three business days of our receipt of an expedited authorization request or (2) in all other cases, within 3 business days of receipt of necessary information but no more than 14 days of the request. For concurrent review requests, the time frame for a decision is (1) within 1 business day of receipt of necessary information but no more than 3 business days of an expedited authorization request or (2) in all other cases, within 1 business day of receipt of necessary information but no more than 14 days of the request.

    For Retrospective Review Requests

    EmblemHealth must make a decision and notify member by mail on the date of the payment denial, in whole or in part. The decision must be made within 30 days of receipt of the necessary information.

    EmblemHealth may reverse a prior approval treatment, service or procedure on retrospective review pursuant to section 4905(5) of PHL when:

    • Relevant medical information presented to EmblemHealth or the utilization review agent upon retrospective review is materially different from the information that was presented during the prior approval review; and
    • The information existed at the time of the prior approval review but was withheld or not made available; and
    • EmblemHealth or the utilization review agent was not aware of the existence of the information at the time of the prior approval review; and
    • Had they been aware of the information, the treatment, service or procedure being requested would not have been authorized.

    Expedited Review Requests

    Expedited review requests must be conducted when EmblemHealth or the provider indicates delay would seriously jeopardize the member's life or health or ability to attain, maintain or regain maximum functions. Members have the right to request expedited review, but EmblemHealth may deny and notice will process under standard time frames.

    Extensions for Expedited and Standard Review Time Frames

    Reviews of expedited and standard reviews of prior approval and concurrent review requests may be extended by an additional 14 days if:

    (1) The member, designee or provider requests an extension; or

    (2) EmblemHealth demonstrates there is a need for more information and the extension is in the member's interest. Notice of extension will be provided to the member.

    Notice to members regarding an extension initiated by EmblemHealth shall include:

    • The reason for the extension.
    • An explanation of how the delay is in the best interest of the member.
    • A description of any additional information that EmblemHealth requires to make its determination.
    • Information regarding the member's right to file a complaint regarding the extension.
    • The process for filing a complaint and the time frames within which a complaint determination must be made.
    • The member's right to designate a representative to file a complaint on his/her behalf.
    • Information regarding the member's right to contact the New York State Department of Health, including a toll-free number.

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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 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.

    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.

    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.

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

    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 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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