Table of Contents
How Do I...

Search Tips

Table of Contents Search

  • For more specific results, select both a chapter and section.
  • To move from section to section within a chapter, use the left navigation bar.

Keyword Search

  • For best results, select a recommended search term if one appears in the search box.
  • To narrow your search, use the Filter By and Additional Keywords features in the left navigation bar.
  • To find an exact phrase, use quotes (e.g., “prior approval”).
  • To find all search terms, use the word AND in capital letters between search terms.
  • To find at least one search term, use the word OR in capital letters between search terms.
  • Dispute Resolution for Commercial and CHP Plans > Final Adverse Determinations

    For decisions that uphold or partially uphold a determination made regarding a clinical issue for which no additional internal appeal options are available, EmblemHealth will issue a final adverse determination (FAD) in writing to the member and provider.

    The FAD contains the following information:

    • The basis and clinical rationale for the determination.
    • The words "final adverse determination."
    • EmblemHealth contact person and phone number.
    • The member's coverage type.
    • EmblemHealth's contact person or UR agent, address and phone number.
    • A summary of the appeal.
    • The date the appeal was filed.
    • The date the appeal process was completed.
    • The health service that was denied, including the name of the facility/provider and developer/manufacturer of the health care service as available.
    • A statement that the member may be eligible for external appeal and time frames for appeal.
    • A standard description of external appeals process, including a clear statement in bold that the member/designee has 4 months and the provider has 60 days (45 days before July 1, 2014) from the final adverse determination to request an external appeal and choosing a second level of internal appeal may cause the time to file external appeal to expire. This applies to GHI PPO FEHB plan members only.
    • Standard description of external appeals process attached.
    • The terms "medical necessity", "experimental/investigational", "out-of-network", "clinical trial" or "rare disease treatment".
    • Information on available alternative and/or external dispute resolution options.

      Notice of Final Appeal Determination

      EmblemHealth will notify the member or member's designee in writing of the final appeal determination within two business days of when we make the decision. However, written notice of final adverse determination concerning an expedited utilization review appeal shall be transmitted to the member within 24 hours of rendering the determination.

      My Subscriptions

      Enter your e-mail address to receive a link to your subscriptions.


      Glossary terms found on this page:

      A determination by EmblemHealth or its agents that an admission, extension of stay or other health care service has been reviewed and, based on the information provided, is not medically necessary.

      Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.

      Information relating to the patient's health.

      A statement that provides additional clarification of the clinical basis for a noncertification determination. The clinical rationale should relate the noncertification determination to the patient's condition or treatment plan, and should supply a sufficient basis for a decision to pursue an appeal.

      A person authorized by the insured to assist in obtaining access to, or payment to, the insured for health care services. If the insured has already received health care services and has no liability for payment of services, a designee will not be authorized for the purpose of requesting an external appeal.

      Written request for an independent entity that has been certified by the State to conduct a review of a denial of coverage, based on lack of medical necessity or that the service requested is experimental and investigational.

      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.

      Final determination made on a first level utilization review appeal, where an initial adverse determination has been upheld.

      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.

      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.

      The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

      The use of health care providers who have not contracted with the health plan to provide services. Depending on the member's contract, out-of-network services may not be covered.

      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.

      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 formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. Also called Coordinated Care.


    You are now leaving the Medicare section of the EmblemHealth website.

    Click to Continue ×

    Your member ID # is on the front of your ID card.