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  • Dispute Resolution for Medicare Plans > Initial Adverse Determinations

    EmblemHealth will send a written notice on the date when a request for health care service, procedure or treatment is given an adverse determination (denial) on the following grounds:

    • Service does not meet or no longer meets the criteria for medical necessity, based on the information provided to us.
    • Service is considered to be experimental or investigational (rare disease).
    • Elective non-urgent service requested by an out-of-network provider can be provided by a participating provider, and there is no medical necessity to access an out-of-network provider.
    • Service is approved, but the amount, scope or duration is less than requested.
    • Service is not a covered benefit under the member's benefit plan.
    • Service is a covered benefit under the member's benefit plan, but the member has exhausted the benefit for that service.

      The written notice will be sent to the member and provider and will include:

      • The description of the action EmblemHealth has taken or intends to take.
      • The reasons for the initial adverse determination, including the clinical rationale,
        if any.
      • The member's right to file an appeal, including the member's right to designate a representative to file an appeal on his or her behalf.
      • The process and time frame for filing/reviewing an appeal with EmblemHealth, including
        • an explanation that an expedited review of the appeal can be requested if a delay would significantly increase the risk to a member's health.
        • a toll-free number for filing an appeal.
      • Instructions on how to initiate an appeal and time frames for submitting the appeal.
      • Notice of the availability, upon request of the member or the member's designee, of the clinical review criteria relied upon to make such determination.
      • EmblemHealth's time frame for making a decision on an appeal.

        For retrospective review requests, EmblemHealth must make a decision and notify the member by mail on the date of the payment denial, in whole or in part. The decision must be made within 60 calendar days of receipt of the request.

        EmblemHealth may reverse a prior approval decision for a treatment, service or procedure on retrospective review 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.
        • The information existed at the time of the prior approval review but was withheld or not made available.
        • EmblemHealth or the utilization review agent was not aware of the existence of the information at the time of the prior approval review.
        • Had they been aware of the information, the treatment, service or procedure being requested would not have been authorized.

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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.

        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.

        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.

        Occurs when a clinical professional reviews information about a patient's health.

        The written screens, decision rules, medical protocols or guidelines used by the utilization management agent as an element in the evaluation of medical necessity and appropriateness of requested admissions, procedures and services under the auspices of the applicable health benefit plan.

        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.

        Initial determination made by a utilization management agent for a denial of a service authorization request on the basis that the requested service is not medically necessary or an approval of a service authorization in an amount, duration or scope is less than requested.

        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.

        The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

        A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A network provider is a member of the EmblemHealth network of network providers applicable to the member's certificate. Therefore, they are sometimes referred to as participating providers. Payment is made directly to a network provider. Please consult the EmblemHealth Directory or go online to search for network providers.

        The use of health care providers who have not contracted with the health plan to provide services. Depending on the member's contract, out-of-network services may not be covered.

        A health care provider, such as a physician, skilled nursing facility, home health agency or laboratory, that does not have an agreement with EmblemHealth plans to provide covered services to members. Also called a Non-Participating Provider.

        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.

        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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