FIDA Plan policies and procedures for participant grievances include the following:
- Participants are entitled to file grievances directly with EmblemHealth.
- EmblemHealth must send written acknowledgement of grievances to the participant within 15 days of receipt.
- If a decision is reached before the written acknowledgement is sent, EmblemHealth will not send the written acknowledgment.
- The grievance must be decided as fast as the participant’s condition requires but not later than:
- Expedited: Paper review – decision and notification within 24 hours (in certain circumstances outlined in the Memorandum of Understanding). For all other circumstances where a standard decision would significantly increase the risk to a participant’s health, decision and notification within 48 hours after receipt of all necessary information and no more than 7 calendar days from the receipt of the grievance.
- Standard: Notification of decision within 30 calendar days of EmblemHealth receiving the written or oral grievance.
- EmblemHealth must notify the participant of the decision by phone for expedited grievances and provide written notice of the decision within 3 business days of decision (expedited).
- EmblemHealth tracks and resolves all grievances or reroutes grievances to the coverage decision or appeals process as appropriate
- EmblemHealth has internal controls in place to identify incoming requests as grievances, initial requests for coverage, or appeals, and has processes to ensure that such requests are processed through the appropriate avenues in a timely manner.
EmblemHealth notifies FIDA participants of all Medicare and Medicaid appeal rights through a single notice specific to the service or item type in question.
EmblemHealth maintains policies and procedures for participant appeals, in accordance with the requirements specified in the CMS-State Memorandum of Understanding. These policies and procedures include the following:
- Participants are entitled to file appeals directly with EmblemHealth. The appeal must be requested within 60 days of postmark date of notice of action if there is no request to continue benefits while the appeal decision is pending. If there is a request to continue benefits while the appeal decision is pending and the appeal involves the termination or modification of a previously authorized service, the appeal must be requested within 10 days of the notice’s postmark date or by the intended effective date of the action, whichever is later.
- Upon receipt of an appeal, EmblemHealth sends written acknowledgement of appeal to the participant and their providers or representatives (if the participant did not file the appeal) within 15 calendar days of receipt. If a decision is reached before written acknowledgement is sent, EmblemHealth will not send the written acknowledgement.
- EmblemHealth decides and notifies the participant (and provider, as appropriate) of its decision as fast as the participant’s condition requires but:
- Expedited: Paper review unless a participant requests in-person review - as fast as the participant’s condition requires, but no later than within 72 hours of the receipt of the appeal.
- Standard: Paper review unless a participant requests in-person review - as fast as the participant’s condition requires, but no later than 7 calendar days from the date of the receipt of the appeal on Medicaid prescription drug appeals and no later than 30 calendar days from the date of the receipt of the appeal.
- Extension: An extension may be requested by a participant or provider on a participant’s behalf (written or oral). EmblemHealth may also initiate an extension if it can justify need for additional information and if the extension is in the participant’s interest. In all cases, the extension reason must be well-documented, and when EmblemHealth requests the extension it notifies the participant in writing of the reasons for delay and informs the participant of the right to file an expedited grievance if he or she disagrees with EmblemHealth’s decision to grant an extension.
- EmblemHealth makes a reasonable effort to provide prompt oral notice to the participant for expedited appeals and document those efforts. EmblemHealth sends written notice within 2 calendar days of providing oral notice of its decision for appeals.
For filing instructions, see the Overview and Contacts section of this chapter.
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 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 available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).
The government agency responsible for administering the Medicare and Medicaid programs.
The date on which the coverage of an insurance policy goes into effect at 12:01 am.
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.
A managed care plan under contract with the Centers for Medicare & Medicaid Services and the State to provide the fully-integrated Medicare and Medicaid benefits under the FIDA demonstration. Also called fully-integrated duals advantage plan.
A request to change an adverse determination that was based on administrative policies, procedures or guidelines.
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.
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.
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 written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.
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.