The descriptions below provide a general overview of the dispute resolution terminology used with Medicare Advantage plans.
A request to review any aspect of a claim determination or adverse benefit determination or a clinical adverse determination denied with regards to medical necessity.
- Coverage Determination
A notification sent when a Part D drug is denied.
A request to review an administrative process, service or quality of care issue NOT pertaining to a medical necessity determination, a benefit determination or a claims determination.
- Organization Determination
A notification sent when a health care service, procedure or treatment is denied.
Medicaid Advantage plans include coverage components from both Medicare Advantage and Medicaid managed care. These dual-eligible members have the right to select which dispute process to use. In the written notice of initial adverse determination to all dual-eligible members, EmblemHealth will provide notice that:
- A Medicare appeal must be filed within 60 days from the date of the denial.
- Filing a Medicare appeal means that the member cannot file for a state fair hearing.
- The member may still file for Medicare appeal after filing for Medicaid appeal, if it is within the 30-day period.
Certain disputes may be filed as Expedited or Standard depending on the urgency of the patient's condition.
Certain disputes may also be filed as Pre-Service or Post-Service depending on the timing of the determination in question.
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.
Appointing a Designee
Members wishing to dispute a determination or claim denial may do so themselves or designate a person or practitioner to act on their behalf. To appoint a designee, members must submit by fax or by mail a signed Appointment of Representative (AOR) form or a Power of Attorney form that specifies the individual as an authorized party.
In certain circumstances, dispute resolution time frames may be extended if permitted by law and requested by the complainant or if EmblemHealth believes an extension is in the best interest of the member.
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.
Services that have been approved for payment based on a review of EmblemHealth's policies.
An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.
A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
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 request to change an adverse determination that was based on administrative policies, procedures or guidelines.
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 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 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. Also known as MA.
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.
A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.
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.