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  • Dispute Resolution for Medicare Plans > Member Dispute Resolution Procedures: Grievances and Appeals

    The processes members need to follow if they want to report a problem, file a complaint or submit an appeal are documented in the members' Evidence of Coverage. This is the same process a provider would follow when acting on behalf of a member. Copies of each Medicare plan's Evidence of Coverage can be found on our Web site at www.emblemhealth.com/Our-Plans/Medicare.aspx by searching under the applicable plan.

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    Glossary terms found on this page:

    Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the 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 health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    A request to change an adverse determination that was based on administrative policies, procedures or guidelines.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    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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