Grievances

A grievance is any complaint other than one that involves a coverage determination. A grievance can be about issues you have with our health care professionals or EmblemHealth staff, such as:

  • The quality of your care; waiting times for appointments at the doctor’s office.
  • The way your doctor, nurse, receptionist or other staff behaves.
  • Being able to reach someone by phone.
  • Getting the information you need.
  • The cleanliness or condition of the doctor’s office.
  • Dissatisfaction with wait times when filling a prescription.
  • The cleanliness or condition of a pharmacy that contracts with EmblemHealth

You or your representative must file a grievance no later than 60 days after the event or incident that caused the grievance. If a request to have a coverage decision, coverage determination, reconsideration or coverage re-determination expedited is denied, you can file an expedited grievance.

All grievances can be filed by writing, by phone, or 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
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

Grievances submitted orally may be answered either orally or in writing unless you ask for a written response. All grievances about quality of care, no matter how the grievance is filed, will be answered in writing.

We will tell you our finding as quickly as needed based upon your health status. This will be no later than 30 days after the date we receive your grievance.

This time period may be extended by up to 14 days if you ask for such an extension. It may also be extended if we can prove it is needed.

If we extend the time frame, you will be told immediately. Expedited grievances will be answered within 24 hours.

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

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