Provider Rights When a Procedure is Denied

Denied ProceduresThere may be times in the course of providing treatment that EmblemHealth or its delegate may make an adverse determination (denial) of a request for a particular service, procedure or treatment. The adverse determination must be made in writing and identify the specific date of service(s) in question. Depending on timing, they may be called an Initial Adverse Determination (IAD) or a Final Adverse Determination (FAD). Adverse determinations can be made on any of the following grounds:

  • Service does not meet or no longer meets the criteria for medical necessity, based on the information provided to us or our delegate.
  • Service is considered experimental/investigational, a clinical trial or may be for rare disease treatment.
  • Service is approved, but the amount, scope or duration is less than requested.

Submitting an Appeal

Both you and the member have the right to appeal an adverse determination. If you believe that the requested service is medically necessary, and that it requires an expedited (or fast) appeal, you may submit the request via fax or email directly to the Medical Review Unit of EmblemHealth (for appeals that are handled by EmblemHealth*). The Provider Manual includes three chapters that discuss dispute resolution, including:

  1. Dispute Resolution for Commercial and Child Health Plus Plans
  2. Dispute Resolution for Medicaid Managed Care and Family Health Plus Plans
  3. Dispute Resolution for Medicare Plans

The fax number is 1-866-350-2168 and the email address is MRU@emblemhealth.com. Note that although you can choose to mail or call in the request to EmblemHealth, faxing or emailing are the quickest and most efficient methods. Please submit all clinical information with your request and provide your contact information to ensure the EmblemHealth Medical Review Unit staff is able to reach you when additional information is required.

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*If the denial letter directs you to contact one of our delegates — such as Health Care Partners (HCP), Contract Maintenance Organization (CMO), Care Core National, Value Options, ICORE or Palladian — please follow the instructions in the denial letter.

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