If a member, designee, practitioner acting on member's behalf or practitioner acting on their own behalf is not satisfied with an action, including a medical necessity determination, experimental/investigational determination, rare disease determination or (in certain instances) out-of-network determination - and a delay would seriously jeopardize the member's life, health or ability to attain, maintain or regain maximum function - the member may request an expedited action appeal.
The member or designee may request expedited review of a prior authorization request or concurrent review request. EmblemHealth's time frame to file the appeal is at least 90 calendar days after notification to the member of the UR decision.
An expedited appeal may be filed:
- For continued or extended health care services, procedures or treatments.
- For additional services for member undergoing a course of continued treatment.
- When the health care provider believes an immediate appeal is warranted.
- When EmblemHealth honors the member's request for an expedited review.
Process for Filing an Expedited Action Appeal
Expedited action appeals should be accompanied by a copy of the action, an explanation outlining the details of the request for a review and all documentation to support a reversal of the decision. The utilization review appeal may be filed in writing or by telephone.
Time Frame for Expedited Action Appeal Decisions
The review time frame begins upon receipt of the appeal, whether filed orally or in writing. If EmblemHealth requires information necessary to conduct an expedited appeal, EmblemHealth shall immediately notify the member and the member's health care provider by telephone or by fax to identify and request the necessary information followed by written notification.
An expedited appeal will be decided as fast as the member's condition requires and within two business days of receipt of the necessary information, but no more than three business days of receipt of the appeal. This time may be extended for up to 14 days upon the member or provider's request, or if EmblemHealth demonstrates more information is needed and a delay is in best interest of member and so notifies member.
Denial of an Expedited Action Appeal Request
EmblemHealth may deny the member's request for expedited review and the notice of action will be processed under standard action appeal time frames. If EmblemHealth denies the member's request for an expedited review, EmblemHealth must immediately provide notice by phone, followed by written notice within two days of the denial.
Expedited appeals not resolved to the satisfaction of the appealing party may be re-appealed via the standard appeal process or through the external appeal process.
Review of Expedited Action Appeal Requests
The review will be conducted by a qualified EmblemHealth medical director who was neither involved in prior determinations nor the subordinate of any person involved in the initial adverse determination. A clinical peer reviewer will be available to discuss the action appeal within 1 business day.
Before and during the appeal review period, the member or designee may see their case file. The member may present evidence to support their appeal in person or in writing.
Expedited action appeals will be reviewed and a 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. EmblemHealth will make reasonable efforts to provide oral notice to the member and provider at the time the determination is made. Failure by EmblemHealth to make a determination with the applicable time periods in this section shall be deemed to be a reversal of the utilization review agent's adverse determination. Procedures for initiating an expedited action appeal are as follows:
Table 22-2: Expedited Action Appeals Procedures for Members
WHAT/HOW/WHERE TO FILE: INSTRUCTIONS
Initial Member Filing
EmblemHealth Acknowledges Receipt
EmblemHealth Determination Notification
Expedited Appeal Line
Expedited Appeal Line
For actions issued by eviCore, file appeals with eviCore
For actions issued by Palladian Health, file appeals with Palladian Health
Within 90 calendar days from receipt of written adverse determination
Expedited determinations are made more quickly than the time frame to send the acknowledgement letter
Within 2 business days from receipt of all necessary information or 3 business days from receipt of action appeal request
May be extended for up to 14 days for reasons noted in Extensions above
May appeal using our standard action appeal process
Additional complaints may be filed with the
NYSDOH at any time by calling
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
Oral or written request for EmblemHealth to review or reconsider an action by EmblemHealth or its subcontractor.
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.
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
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.
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.
Final determination made on a first level utilization review appeal, where an initial adverse determination has been upheld.
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.
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.
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.
Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.
A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.
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 state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called the New York State Department of Health.
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
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- 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.
New York State Department of Health. This agency provides information for consumers, doctors, researchers and health care providers.
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.