Appeals

An appeal is the type of complaint you make when you want us to change a decision we have made about what services or benefits are covered. It could also be about what we will pay for a service or benefit (including Part D services and benefits).

Standard Reconsiderations

Reconsideration is a request from a member, their designee or non-contracted health care professional to reverse or change:

  • An initial determination to deny.
  • Reduce or discontinue services. Or
  • The denial of payment for medical care.

The time frame for filing reconsideration is 60 calendar days from the date of the notice of the adverse determination. This may be extended if the member shows good cause (this must be requested in writing including the reason that it was not filed timely).

For reconsiderations for services that have not been rendered yet (pre-service reconsiderations):

  • We must make our reconsidered determination as quickly as the member’s health condition requires. This will be no later than 30 calendar days from the date we receive the request for a standard reconsideration.
  • The time frame will be extended by up to 14 calendar days by us if the member requests the extension.
  • We also may be extend by up to 14 calendar days if we justify a need for more information and document how the delay is in the best interest of the member.
  • When we extend the time frame, we will notify the member in writing of the reasons for the delay. We inform the member of the right to file an expedited grievance if the member disagrees with our decision to grant itself an extension.

For reconsiderations for a request for reimbursement (services that have already been received and you have paid for):

  • We must make our reconsidered determination no later than 60 calendar days from the date we receive the request.

Standard reconsiderations can be filed by mail, phone, by fax to:

EmblemHealth Medicare HMO
Attn: Grievance & Appeals
PO Box 2807  
New York, NY 10116-2807
Phone: 1-877-344-7364
TTY: 711
Fax: 1-212-510-5320

Standard Part D Coverage Redeterminations

A coverage redetermination is a request to have an unfavorable coverage determination reviewed or reconsidered for Part D. This includes decisions made by the plan about coverage of a Part D benefit or what amount the plan will pay for a drug.

A member, their authorized representative, or the provider acting on the member’s behalf must file their request for a redetermination within 60 calendar days of the date of the notice of the coverage determination. This may be extended if the member shows good cause (this must be requested in writing including the reason that it was not filed timely).

Standard Redeterminations

  • We will make the determination and give notice within 7 calendar days of receiving the request.
  • If we approve a request for coverage, we must authorize the drug as quickly as your health requires, but no later than 7 calendar days after we receive your request for redetermination.
  • If we approve your request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your redetermination request.

Standard coverage redetermination requests can be filed by mail, by phone, by fax or by email to:

EmblemHealth Medicare HMO
Attn: Grievance & Appeals
PO Box 2807  
New York, NY 10116-2807
Phone: 1-877-344-7364
TTY: 711
Fax: 1-212-510-5320
EmblemHealth Medicare PDP
Attn: Grievance & Appeals
PO Box 2807  
New York, NY 10116-2807
Phone: 1-877-444-7241
TTY: 711
Fax: 1-212-510-5320

Email: PartDStandardAppeals@emblemhealth.com

Medicare Prescription Drug Coverage Redetermination Request Form

More information about grievances, coverage decisions, coverage determinations and appeals is available. If you are an EmblemHealth Medicare HMO member, please see Chapter 9 of your Evidence of Coverage.

2018 Important Plan Documents

2017 Important Plan Documents

Nondiscrimination Policy

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