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  • Dispute Resolution for Medicare Plans > Provider Dispute Resolution Procedures: Complaints and Grievances


    Practitioner Complaint Procedures

    If a practitioner is dissatisfied with an administrative process, quality of care issue and/or any aspect of service rendered by EmblemHealth that does not pertain to a benefit or claim determination, the practitioner may file a complaint on his/her own behalf. Examples of such dissatisfaction include:

    • Long wait times on EmblemHealth's authorization phone lines
    • Difficulty accessing EmblemHealth's systems
    • Quality-of-care issues

    Once a decision is made on a practitioner's complaint, it is considered final and there are no additional internal review rights.

    Complaints must be submitted in writing to the EmblemHealth's Grievance and Appeals (GAD) department. A complaint should include a detailed explanation of the clinician's request and any documentation to support the practitioner's position.

    The Plan will acknowledge receipt of the practitioner's complaint in writing no later than 15 days after its receipt. Practitioner complaints will be reviewed and a written response will be issued directly to the practitioner no later than 30 days after receipt.

    Contracted Provider Grievance Process for Medicare HMO and PPO Plans

    If a provider is not satisfied with any aspect of a claim determination rendered by the plan (or any entity designated to perform administrative functions on its behalf) which does not pertain to a medical necessity determination, that provider may file a grievance with EmblemHealth.

    Examples of reasons for filing grievances include dissatisfaction with a decision resulting from a failure to follow a plan policy or procedure, or failure to obtain prior approval for an inpatient admission. A provider may also file a grievance regarding how a claim was processed, including issues such as computational errors, interpretation of contract reimbursement terms, or timeliness of payment. The Grievance and Appeal department is not involved in determining claim payment or authorizing services, but independently investigates all grievances.

    In addition, providers who wish to challenge the recovery of an overpayment or request a reconsideration for claims denied exclusively for untimely filing may follow the grievance procedures in this sub-section.

    Note: The right to reconsideration shall not apply to a claim submitted 365 days after the service date. If a claim was submitted more than one year from date of service, EmblemHealth may deny the claim in full or in the alternative may reduce payments by up to 25 percent of the amount that would have been paid had the claim been submitted in a timely manner.

    For grievances related to untimely filing, the provider must demonstrate that the late submission was an unusual occurrence and that they have a pattern of submitting claims in a timely manner. Examples of an unusual occurrence include:

    • Medicaid Reclamation
    • Member submitted the provider the wrong insurance information
    • Coordination of Benefits related issues
    • Member retroactively reinstated

    The provider has the option to question a claim's payment by submitting an inquiry along with supporting documentation within the Claim's Inquiry tool in the secure provider website: www.emblemhealth.com/Providers. For multiple claims, use the Message Center tool to send grievance and attach files.

    The grievance should be accompanied by a copy of the notice of the standard denial or other documentation of the denial, an explanation outlining the details of the request for a review and all documentation to support a reversal of the decision.

    EmblemHealth will acknowledge, in writing, receipt of a grievance that is submitted in writing no later than 15 days after its receipt. The grievance will be reviewed and a written response will be issued for grievances with a final disposition of partial overturn or upheld, no later than 45 days after receipt. The determination included in the response will be final.

    Grievances with a favorable disposition will receive a claims remittance advice in lieu of a written response no later than 45 days after receipt.

    Procedures for initiating a Contracted Provider Grievance with respect to an EmblemHealth Medicare member are outlined in the table below.

    Notice of Determinations of Grievance Decision

    The written Notice of Determination will include the following:

    • The date the request was received
    • Detailed reasons for the determination, including the clinical rational if applicable.
    • A statement that the notice is a final determination
    • Notice that the member and EmblemHealth will be held harmless

    TABLE 23-1, PROVIDER COMPLAINT/GRIEVANCE PROCEDURES
    EMBLEMHEALTH MEDICARE HMO AND PPO PLANS

    BENEFIT PLAN(S)

    WHAT/HOW/WHERE TO FILE HARD COPY **:

    INSTRUCTIONS

    TIME FRAMES*

    ADDITIONAL RIGHTS

    Initial
    Practitioner Filing

    EmblemHealth Acknowledges Receipt

    EmblemHealth Determination Notification

    EmblemHealth Medicare HMO Plans

    Sign in to: www.emblemhealth.com.

    Write to:
    EmblemHealth
    Medicare HMO
    P.O. Box 2807
    New York, NY 10116-2807

    45 calendar days from event. Exceptions: SUNY Downstate - 90 calendar days from event; Stony Brook Affiliations - 120 calendar days from event.

    15 calendar days from receipt of request.

    Complaint: 30 calendar days from receipt of request.

    Grievance: 45 calendar days from receipt of request.

    Decision is final.

    EmblemHealth Medicare PPO Plans

    Sign in to: www.emblemhealth.com.

    Write to:
    EmblemHealth
    Medicare PPO
    PO Box 2807
    New York, NY 10116-2807

    45 calendar days from event.

    15 calendar days from receipt of request.

    Complaint: 30 calendar days from receipt of request.

    Grievance: 45 calendar days from receipt of request.

    Decision is final.

    * Contracted facility time frames in provider agreements will supersede time frames in this manual.

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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

    Formal acceptance as an inpatient by an institution, hospital or health care facility.

    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.

    Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    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 legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

    When a member is covered by more than one benefit plan, with both providing similar benefits, EmblemHealth coordinates with the other carrier to ensure appropriate reimbursement. Also called COB.

    The date on which a service was rendered.

    An individual other than the subscriber who is eligible to receive health care services under the member's Certificate of Insurance. Generally, dependents are limited to the subscriber's spouse and eligible children.

    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.

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

    A complaint process whereby the member, or the member's duly authorized representative, may seek review of benefit determinations or other determinations made by EmblemHealth or a delegate relating to the member's health plan.

    An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

    Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

    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.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    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 type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    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 request for inpatient review, made while the member is still in the facility, of a case that was denied on the basis of medical necessity.

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