Contracted Facility Clinical Appeals - Medicare HMO Plans
If an EmblemHealth-contracted facility is not satisfied with an initial adverse determination related to an EmblemHealth Medicare HMO member for a retrospective review that was rendered based on issues of medical necessity, experimental or investigational use, or services cannot be approved because the facility has not submitted information to establish medical necessity, an appeal may be filed. EmblemHealth provides one internal level of appeal for facilities. EmblemHealth will acknowledge receipt of the appeal request in writing within 15 calendar days.
EmblemHealth handles all facility clinical appeals, except in the following situations, where the managing entity handles the appeal:
- If the managing entity has a direct contract with the facility.
- The managing entity has denied the case based on medical information.
- The managing entity has denied the case for "no information."
An EmblemHealth medical director reviews appeals. Personnel who have previously rendered decisions in the case or subordinate(s) of that person are not permitted to render a decision on the appeal.
EmblemHealth or the managing entity will render a decision within 60 days of receipt of the appeal request.
Procedures for initiating a contracted facility clinical appeal are outlined in the table below:
WHAT/HOW/WHERE TO FILE:
Initial Provider* Filing
EmblemHealth Acknowledges Receipt
EmblemHealth Determination Notification
EmblemHealth Medicare HMO Plans
PO Box 2807
New York, NY 10116-2844
45 calendar days from receipt of written adverse determination. Exceptions: NY Presbyterian - 365 calendar days from discharge date or 60 calendar days from denial date (whichever is later); Long Island Health Network - 60 calendar days; SUNY Downstate - 120 calendar days.
15 calendar days from receipt of request.
60 calendar days from receipt of request.
The provider notified within 2 days of determination.
* Contracted facility time frames in provider agreements will supersede time frames in this manual.
For Medicare PPO facility disputes, please refer to the Contracted Provider Grievances - Medicare PPO Plans section in this chapter.
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.
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 legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
Date the patient left the hospital.
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.
A request to change an adverse determination that was based on administrative policies, procedures or guidelines.
An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.
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.
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.
A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.
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 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.
A review done after services are completed (usually as part of a claim or appeal) that ensures the care given was medically necessary.