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  • Dispute Resolution for Commercial and CHP Plans > Initial Adverse Determinations

    EmblemHealth will send a written notice on the date when a health care service, procedure or treatment is given an adverse determination (denial) on the following grounds:

    • Service does not meet or no longer meets the criteria for medical necessity, based on the information provided to us.
    • Service is considered to be experimental or investigational (rare disease, clinical trial and out-of-network services).
    • Service is approved, but the amount, scope or duration is less than requested.
    • Service is not a covered benefit under the member's benefit plan.
    • Service is a covered benefit under the member's benefit plan, but the member has exhausted the benefit for that service.

    The written notice will be sent to the member and provider and will include:

    • The reasons for the determination, including the clinical rationale, if any.
    • Instructions on how to initiate internal appeals (standard and expedited appeals) and eligibility for external appeals.
    • Notice of the availability, upon request of the member or the member's designee of the clinical review criteria relied upon to make such determination.
    • A description of what additional information, if any, must be provided to, or obtained by, EmblemHealth in order for EmblemHealth to make an appeal determination.
    • The description of the Action to be taken.
    • A statement that EmblemHealth will not retaliate or take any discriminatory action against the member if an appeal is filed.
    • The process and time frame for filing/reviewing an appeal with EmblemHealth, including the member's right to file an expedited review.
    • The member's right to contact the DOH, with 1-800 number regarding their complaint.

    The failure of EmblemHealth to make a utilization review (UR) determination within the time periods prescribed in the Care Management chapter is deemed to be an adverse determination subject to appeal. EmblemHealth must send notice of denial on the date that the utilization review's time frames expire.


    When an adverse determination is rendered without provider input, the provider has the right to reconsideration. The reconsideration shall occur within one business day of receipt of the request (except for retrospective, which is within 5 days) and shall be conducted by the member's health care provider and the clinical peer reviewer making the initial determination. See the Care Management chapter for more information.

    Retrospective Review Requests

    For retrospective review requests, EmblemHealth must make a decision and notify member by mail on the date of the payment denial, in whole or in part. The decision must be made within 30 days of receipt of the necessary information.

    EmblemHealth may reverse a prior approval decision for a treatment, service or procedure on retrospective review pursuant to section 4905(5) of PHL when:

    • Relevant medical information presented to EmblemHealth or the utilization review agent upon retrospective review is materially different from the information that was presented during the prior approval; and
    • The information existed at the time of the prior approval review but was withheld or not made available; and
    • EmblemHealth or the utilization review agent was not aware of the existence of the information at the time of the prior approval review; and
    • Had they been aware of the information, the treatment, service or procedure being requested would not have been authorized.

    Home Health Care Determinations Following an Inpatient Hospital Admission

    EmblemHealth will provide notice of our determination within one business day of receipt of the necessary information, or if the day after the request for services falls on a weekend or holiday, within 72 hours of receipt of necessary information. If a request for home health care services and all necessary information is provided to us prior to a member's inpatient hospital discharge, we will not deny the home care coverage request on the basis of a lack of medical necessity or a lack of prior authorization while the review determination is pending. There may, however, be other reasons for denying the service such as the exhaustion of a benefit. Denials for home health services following a discharge from a hospital admission will be treated as expedited appeals.

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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.

    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.

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    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.

    A physician who possesses a current and valid license to practice medicine or a health care professional other than a licensed physician who:

    • Where applicable possesses a current and valid nonrestricted license, certificate or registration or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body to the profession
    • Is in the same profession and the same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under review

    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.

    Occurs when a clinical professional reviews information about a patient's health.

    The written screens, decision rules, medical protocols or guidelines used by the utilization management agent as an element in the evaluation of medical necessity and appropriateness of requested admissions, procedures and services under the auspices of the applicable health benefit plan.

    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 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.

    A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

    Oral or written request to review or reconsider an initial adverse determination when waiting for a standard decision could seriously harm the enrollee's life, health or their ability to regain maximum function. For pre-service expedited requests, the practitioner may act on behalf of the member. Also called a fast track 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 professionally licensed individual, facility or entity giving health-related care to patients. Physicians, hospitals, skilled nursing facilities, pharmacies, chiropractors, nurses, nurse-midwives, physical therapists, speech pathologist and laboratories are providers. All network providers are health care providers, but not all providers are network providers.

    Health care services rendered to a member in their home in lieu of confinement in a hospital or skilled nursing facility. Care must be under the supervision of a registered professional nurse. This type of care may include physical, occupational or speech therapy, medical supplies and medication prescribed by a doctor.

    An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

    • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
    • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
    • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
    • Maintains medical records for all patients
    • Has a requirement that every patient be under the care of a member of the medical staff
    • Provides 24-hour patient services
    • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

    Initial determination made by a utilization management agent for a denial of a service authorization request on the basis that the requested service is not medically necessary or an approval of a service authorization in an amount, duration or scope is less than requested.

    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.

    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.

    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.

    A review done after services are completed (usually as part of a claim or appeal) that ensures the care given was medically necessary.

    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.


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