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  • Dispute Resolution for Medicare Plans > Final Adverse Determinations

    For decisions that uphold or partially uphold a determination made regarding a clinical issue for which no additional internal appeal options are available to the contracted provider, EmblemHealth will issue a final adverse determination (FAD) in writing to the contracted facility.

    The FAD contains the following information:

    • The date the review request was received.
    • A summary of the review.
    • The results and the reasons for the determination, including the clinical rationale.
    • The words "final adverse determination."
    • A clear statement that the notice constitutes the final adverse determination.
    • The terms "medical necessity" or "experimental/investigational."
    • The member's coverage type.
    • The service in question and, if available and applicable, the name of the provider and developer/manufacturer of the health care service.
    • Information on available alternative and/or external dispute resolution options. To determine if further resolution options are applicable, please refer to your contract agreement.

      Notice of Final Appeal Determination

      We will notify the contracted facility in writing of the final appeal determination within three calendar days of when we make the decision.

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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.

      Information relating to the patient's health.

      A statement that provides additional clarification of the clinical basis for a noncertification determination. The clinical rationale should relate the noncertification determination to the patient's condition or treatment plan, and should supply a sufficient basis for a decision to pursue an appeal.

      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 hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

      Final determination made on a first level utilization review appeal, where an initial adverse determination has been upheld.

      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 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.

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