When a decision regarding an action appeal is upheld in whole or in part, EmblemHealth will issue a final adverse determination (FAD). 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 effort to provide oral notice to the member and provider at the time the determination is made. Written notice of final adverse determination concerning an expedited UR appeal shall be transmitted to the member within 24 hours of rendering the determination.
Notices to members of final action appeal adverse determinations will be in writing, dated and include:
- 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 action appeal.
- The date the action 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.
- Standard description of external appeals process attached.
- Summary of appeal and date filed.
- Date appeal process was completed.
- Description of enrollee's fair hearing rights if not included with initial denial.
- Right of member to complain to the Department of Health at any time with 1-800 number.
- A statement that notice available in other languages and formats for special needs and how to access these formats.
For action appeals involving medical necessity or an experimental or investigational treatment, a clinical trial, rare disease or in certain instances out of-network services, the final adverse determination notice shall also include:
- A clear statement that the notice constitutes the final adverse determination, and specifically use the terms "final adverse determination", "medical necessity" or "experimental/investigational", "clinical trial", "rare disease", or in certain instances, "out of network."
- A list of titles and qualifications of the individuals participating in the review, including the title and specialty of the clinical peer reviewer.
- A copy of the "Standard Description and Instructions for Health Care Consumers to Request an External Appeal" and the External Appeal application form.
Managing Entities' Role in Dispute Resolution
EmblemHealth contracts with separate managing entities to provide care for certain types of medical conditions. In these cases, the designated managing entity will determine the applicable process for filing a dispute.
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.
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.
An individual person who is the direct or indirect recipient of the services of the organization. Depending on the context, consumers may be identified by different names, such as "member," "enrollee," "beneficiary" or "patient." A consumer relationship may exist even in cases where there is not a direct relationship between the consumer and the organization. For example, if an individual is a member of a health plan that relies on the services of a utilization management organization, then the individual is a consumer of the utilization management organization.
A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
An individual who is enrolled and eligible for coverage under a health plan contract. Also called a member.
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.
An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.
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.
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.
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.