Grievances and Appeals

Know your rights

You have the right to file a grievance (complaint) or an appeal (ask us to review a request again) if you’re dissatisfied with your plan, your provider, or your treatment by EmblemHealth. You can do this yourself or you can ask someone to act on your behalf.

The information provided below explains how to file grievances and appeals and how to request coverage decisions and coverage determinations in writing, in person and by phone. It also includes the time frames and requirements when processing these requests and the forms you may use to make your request.

If you have any questions or to request the total exceptions, grievances and appeals received by EmblemHealth, please call:

  • EmblemHealth Medicare HMO Customer Service at 877-344-7364 (TTY: 711), 8 am to 8 pm, seven days a week
  • EmblemHealth Medicare PDP (Direct Pay) Customer Service at 877-444-7241 (TTY: 711), 8 am to 8 pm, seven days a week
  • EmblemHealth Medicare PDP (City of New York retirees only) call Customer Service at Express Scripts at 800-585-5786 (TTY: 800-899-2114), 24 hours a day, seven days a week.

You can also contact Medicare directly about your health plan or prescription drug plan.

A grievance is any complaint other than one that involves a coverage determination. A grievance can be about issues you have with our health care professionals or EmblemHealth staff, such as:

  • The quality of your care; waiting times for appointments at the doctor’s office.
  • The way your doctor, nurse, receptionist or other staff behaves.
  • Being able to reach someone by phone.
  • Getting the information you need.
  • The cleanliness or condition of the doctor’s office.
  • Dissatisfaction with wait times when filling a prescription.
  • The cleanliness or condition of a pharmacy that contracts with EmblemHealth.

You or your representative must file a grievance no later than 60 days after the event or incident that caused the grievance. If your request for an expedited coverage decision, reconsideration or coverage re-determination is denied, you can file an expedited grievance.

All grievances can be filed by writing, by phone, or by fax to:

EmblemHealth Medicare HMO
Attn: Grievance & Appeals
PO Box 2807
New York, NY 10116-2807

Phone: 877-344-7364
TTY: 711
Fax: 212-510-5320    

EmblemHealth Medicare PDP
Attn: Grievance & Appeals
PO Box 2807
New York, NY 10116-2807

Phone: 877-444-7241
TTY: 711
Fax: 212-510-5320     

Grievances submitted orally may be answered either orally or in writing unless you ask for a written response. All grievances about quality of care, no matter how the grievance is filed, will be answered in writing.

We will tell you our finding as quickly as needed based upon your health status. This will be no later than 30 days after the date we receive your grievance.

This time period may be extended by up to 14 days if you ask for such an extension. It may also be extended if we can prove it is needed.

If we extend the time frame, you will be told immediately. Expedited grievances will be answered within 24 hours.

There is more information available about grievances, coverage decisions, coverage determinations and appeals; if you are an EmblemHealth Medicare HMO member, please see Chapter 9 of your Evidence of Coverage.

An appeal is the type of complaint you make when you want us to change a decision we have made about what services or benefits are covered. It could also be about what we will pay for a service or benefit (including Part D services and benefits).

Standard Reconsiderations

Reconsideration is a request from a member, their designee or non-contracted health care professional to reverse or change:

  • An initial determination to deny.
  • Reduce or discontinue services. Or
  • The denial of payment for medical care.

The time frame for filing reconsideration is 60 calendar days from the date of the notice of the adverse determination. This may be extended if the member shows good cause (this must be requested in writing including the reason that it was not filed timely).

For reconsiderations for services that have not been rendered yet (pre-service reconsiderations):

  • We must make our reconsidered determination as quickly as the member’s health condition requires. This will be no later than 30 calendar days from the date we receive the request for a standard reconsideration.
  • The time frame will be extended by up to 14 calendar days by us if the member requests the extension.
  • We also may extend by up to 14 calendar days if we justify a need for more information and document how the delay is in the best interest of the member.
  • When we extend the time frame, we will notify the member in writing of the reasons for the delay. We inform the member of the right to file an expedited grievance if the member disagrees with our decision to grant an extension.

For reconsiderations for a request for reimbursement (services that have already been received and you have paid for): We must make our reconsidered determination no later than 60 calendar days from the date we receive the request.

Standard reconsiderations can be filed by mail, phone, by fax to:

EmblemHealth Medicare HMO and PDP
Attn: Grievance & Appeals
PO Box 2807
New York, NY 10116-2807
Phone: 877-344-7364 (TTY: 711) Monday through Sunday, from 8am to 8 pm
Fax: 212-510-5320

Standard Part D Coverage Redeterminations

A coverage redetermination is a request to have an unfavorable coverage determination reviewed or reconsidered for Part D. This includes decisions made by the plan about coverage of a Part D benefit or what amount the plan will pay for a drug.

A member, their authorized representative, or the provider acting on the member’s behalf must file their request for a redetermination within 60 calendar days of the date of the notice of the coverage determination. This may be extended if the member shows good cause (this must be requested in writing including the reason that it was not filed timely).

Standard Redeterminations:

  • We will make the determination and give notice within 7 calendar days for pre-service requests and 14 calendar days if you are requesting payment for a drug you already received.
  • If we approve a request for coverage, we must authorize the drug as quickly as your health requires, but no later than 7 calendar days after we receive your request for redetermination.
  • If we approve your request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your redetermination request.

Standard coverage redetermination requests can be filed by mail, by phone, by fax or by email to:

EmblemHealth Medicare HMO
Attn: Grievance & Appeals
PO Box 2807
New York, NY 10116-2807
Phone: 877-344-7364 (TTY: 711)
Monday through Sunday, from 8 am to 8 pm
Fax: 212-510-5320  
EmblemHealth Medicare PDP
Attn: Grievance & Appeals
PO Box 2807
New York, NY 10116-2807
Phone: 877-444-7241 (TTY:711)
Monday through Sunday, from 8 am to 8 pm
Fax: 212-510-5320     

Email: PartDStandardAppeals@emblemhealth.com

Medicare Prescription Drug Coverage Redetermination Request Form

EmblemHealth Medicare HMO Coverage Redetermination Request Form

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EmblemHealth Medicare PDP Coverage Redetermination Request Form (Including Medicare PDP City of New York Retirees)

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EmblemHealth Medicare PDP Coverage Redetermination Request Form (VIP Rx and VIP Rx Plus)

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If you, your representative or your prescriber feel the standard time frame for an appeal (ask us to review the request again or a coverage redetermination) could seriously risk the member’s life, health, or ability to get back maximum function, you can ask for an expedited appeal.

Expedited Reconsiderations

An expedited request can be filed by a doctor or a member as follows:

  1. For requests filed by a doctor or by a member with a letter from the doctor requesting an expedited appeal: If the request for an expedited reconsideration is made or supported by a doctor, we must grant the expedited reconsideration request. This means the doctor states that the life or health of the member, or the member’s ability to regain maximum function couldbe seriously jeopardized by using the standard time frame.
  2. For requests filed by the member without a letter from the doctor requesting an expedited appeal: If the request is not supported by a doctor, we will determine if the life or health of the member, or the member’s ability to regain maximum function, could be seriously jeopardized by using the standard time frame in the processing of the reconsideration request.

If we deny a request for an expedited reconsideration, we must transfer the request to the standard reconsideration process. We will make a determination as quickly as the member’s health condition requires.

The reconsideration will be no later than 30 calendar days from the date we received the request. We must also provide the member with prompt oral notice that we will process as standard appeal along with the member’s rights.

We also must mail a notice to the member within three calendar days of the oral notification, which explains the following:

  • The request will be processed using the 30-day time frame for standard reconsiderations.
  • The right to file an expedited grievance if the member disagrees with the organization’s decision not to expedite the reconsideration.
  • Instructions about the grievance process and its time frames.
  • The right to resubmit a request for an expedited reconsideration.
  • If the member gets any doctor’s support showing that using the standard time frame for making a determination could seriously jeopardize the member’s life, health or ability to regain maximum function, the request will be expedited automatically.

How We Will Process Your Expedited Appeal

If we process your reconsideration as expedited, we must make a decision and give the member (and the doctor involved, as needed) notice of our reconsideration as quickly as the member’s health condition requires. This will be no later than 72 hours after receiving the request.

We may notify the member orally or in writing. We must notify the member within the 72-hour time frame. We will notify the member orally first and then mail written confirmation to the member within three calendar days.

The 72-hour time frame can be extended by up to 14 calendar days:

  • If the member requests the extension.
  • If EmblemHealth finds a need for additional information and documents how the extension is in the interest of the member

When EmblemHealth extends the time frame:

  • We must notify the member in writing of the reasons for the extension.
  • Inform the member of the right to file an expedited grievance if the member disagrees with EmblemHealth’s decision to grant an extension.
  • We must notify the member of our determination as quickly as the member’s health condition requires, but no later than the last day of the extension.

Expedited Part D Coverage Redeterminations

For expedited redeterminations, a member or their prescribing doctor or other doctor may make an oral or written request for coverage. EmblemHealth will decide if the request should be sped up. Note that expedited redeterminations are not allowed for payment requests. If the request to expedite a coverage redetermination is granted, EmblemHealth will make the determination and give notice within 72 hours of receiving the request. If more medical information is needed, the member and prescribing doctor or another doctor will be told immediately. If the request doesn’t meet expedited criteria, EmblemHealth will notify you promptly and make a decision within seven days.

The notice to the member that the request doesn’t meet expedited criteria will include the following:

  • An explanation of the standard process.
  • The member’s right to file an expedited grievance.
  • The member’s right to resubmit the request with the doctor’s supporting documentation.
  • Instructions about EmblemHealth’s grievance process and its timeframes.

We will also send a written notice within three calendar days after oral notice of the denial.

Expedited appeals can be filed by mail, by phone, by fax or by email to:

EmblemHealth Medicare HMO or EmblemHealth Medicare PDP
Attn: Grievance & Appeals
PO Box 2807
New York, NY 10116-2807
Expedited Phone: 888-447-6855 (TTY: 711)
Expedited Fax: 866-350-2168
Phone and fax are available 24 hours a day, seven days a week

Email: PartDExpeditedMedicareAppeals@emblemhealth.com
The fastest way to get us your expedited appeal is by phone, fax, or email.

More information about grievances, coverage decisions, coverage determinations and appeals is available. If you are an EmblemHealth Medicare HMO member, please see Chapter 9 of your Evidence of Coverage.

A coverage decision is a decision we make about:

  • Your health care products and services coverage or
  • About the amount we will pay for your medical services or medical drugs.

For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from the doctor or if your network doctor refers you to a medical specialist.

You can also contact us and ask for a coverage decision if your doctor:

  • Is unsure if we will cover a health care product or service or
  • Refuses to provide medical care you think that you need.

If you want to know if we will cover a health care product or service before you receive it, you can ask us to make a coverage decision for you. We are making a coverage decision for you when we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare.

If you disagree with this coverage decision, you can request an appeal.
For a standard decision:

  • We will give you our answer within 14 days of receiving your request.
  • We can take up to 14 more days ("an extended time period") for certain issues. If we decide to take extra days to make the decision, we will tell you in writing. If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days.

When you file a fast complaint, we will give you an answer to your complaint within 24 hours. If we do not give you our answer within 14 days (or if there is an extended time period, by the end of that period), you have the right to appeal.

If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 14 days after we received your request. If we extended the time needed to make our decision, we will provide the coverage by the end of that extended period. If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

You can ask our plan to make a coverage decision on the medical care you are requesting. Based on your health, if you need a quick response, you should ask us to make a "fast decision."

To get a fast decision, you must meet two requirements:

  • You can get a fast decision only if you are asking for coverage for health care you have not yet received. You cannot get a fast decision if your request is about payment for medical care you have already received.
  • You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

If your doctor tells us that because of your health the request needs a "fast decision", we will automatically agree to give you a fast decision. If you ask for a "fast decision" on your own, without your doctor's support, our plan will decide if your health requires that we give you a fast decision. If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter (and we will use the standard deadlines instead).

This letter will tell you that if your doctor asks for the fast decision, we will automatically give a fast decision. The letter will also tell how you can file a "fast complaint" about our decision to give you a standard decision instead of the fast decision you asked for.

A fast decision means we will answer within 72 hours. However, we can take up to 14 more calendar days if we find that some information that may benefit you is missing, or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing. If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days.

Coverage decisions can be requested by mail, by phone, by fax to:

EmblemHealth Medicare HMO and PDP
ATTN: Utilization Management
55 Water Street
New York, NY 10041-8190
Phone: 877-344-7364 (TTY: 711)
Monday through Sunday, from 8 am to 8 pm
Fax: 866-215-2928

A coverage determination is a decision by EmblemHealth and it can include the following:

  • To determine coverage for a Part D eligible drug not on EmblemHealth's formulary (list of covered drugs).
  • To determine approval for:
    • A prior authorization (that you will need to get approval from your plan before you fill certain prescriptions),
    • Step therapy (you may need to try a different or more common drug first) or
    • Quantity limit request.
  • To determine approval for tiering (a drug’s level based on cost) exception request.

Coverage determinations include EmblemHealth’s decision on a member’s exception request.

Members may ask us for an exception (change a ruling):

  • To a plan’s tiered cost-sharing (you and your insurance company share the costs of some of the drugs that your plan covers based on the drug’s level) or
  • To cover a drug that is not on our list of covered drugs.

For an exception to be reviewed:

  • The doctor must give supporting documents that the drug on our list of covered drugs would not be as useful (or has not been working as well) and/or
  • The drug may have a negative effect.


Note that certain high cost drugs may not be eligible for the exception process. All drugs approved under the exception process must meet the meaning of a Part D drug. Also, a provider’s statement does not necessarily mean it will be approved.

A member, his or her representative, or the member’s prescribing doctor or other prescriber, may ask for EmblemHealth to expedite a coverage determination when the member or their doctor or other prescriber believes that waiting for a decision under the standard time frame may place the member’s life, health or ability to regain maximum function in serious jeopardy.

You can request a coverage determination by mail, by phone, by fax or by email:

EmblemHealth Medicare HMO or EmblemHealth Medicare PDP
Pharmacy Services
55 Water Street
New York, NY 10041-8190
Phone: 877-444-7097
TTY: 711
Fax: 877-300-9695
Email: PartDCoverageDeterminations@emblemhealth.com

For requests for standard coverage determinations:

  • We will tell the member (and prescribing doctor or other doctor as needed) of the determination as quickly as possible.
  • This will be no later than 72 hours after receipt of the request for the coverage determination.
  • For an exceptions request, no later than 72 hours of receiving the doctor’s supporting statement (if one is provided) is received.


For requests for expedited coverage determinations:

  • A written notice of the determination will be provided by EmblemHealth to the member (and prescribing doctor or other doctor as needed) of the determination within 24 hours of the date of the request or
  • When the doctor’s supporting statement (if one is provided) is received.

If the request to expedite the decision is granted EmblemHealth will give notice to the member (and prescribing doctor or another doctor as needed):

  • Within 24 hours of receiving the request or
  • Within 24 hours of receiving the doctor’s supporting statement.

We will give prompt oral notice of the denial of the expedited request which explains the following:

  1. EmblemHealth’s standard process.
  2. Informs the member of the right to file expedited grievance.
  3. Informs the member of the right to resubmit the request with a doctor’s supporting documentation and
  4. Gives instructions about EmblemHealth’s grievance process and its time frames.

We will also send a written notice within three calendar days after oral notice of the denial. Note that expedited coverage determinations are not allowed for payment requests.

 

Coverage Determination Request Form

EmblemHealth Medicare HMO

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EmblemHealth Medicare PPO

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EmblemHealth Medicare PDP (VIP Rx and VIP Rx Plus)

English  |  Español  |  繁體中文

 

EmblemHealth Medicare PDP (City of New York)

English  |  Español  |  繁體中文

 

To determine if you may need to request a coverage determination or exception, please refer to EmblemHealth’s Part D Formulary.

Nondiscrimination Policy

You can name a relative, friend, advocate, doctor or anyone else to act for you. The individual may already be authorized under state law to act for you such as your power of attorney. The person you name would be your appointed representative.

If you want to give someone permission to act as your appointed representative, you and that person must complete an Appointment of Representative (AOR) Form.

You may also use an equivalent written notice to appoint a representative. The AOR form or written notice with the same information that is needed in the AOR should be sent to the addresses in the Appeals section. This information must be included with your grievance (complaint) or appeal (ask us to review a request again) request.

You also have the right to have a lawyer ask for a coverage determination on your behalf. You can contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services, if you qualify.

 

Appointment of Representative Form

English  |  Español

 

Nondiscrimination Policy

 

Nondiscrimination Policy

 

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Health Insurance Plan of Greater New York (HIP) is an HMO/HMO-POS/HMO D-SNP plan with a Medicare contract. HIP has a contract with the New York Medicaid Program for HMO D-SNP. Enrollment in HIP depends on contract renewal. HIP is an EmblemHealth company. This information is not a complete description of benefits. Call 877-344-7364/TTY: 711 for more information.

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ATTENTION: If you speak other languages, language assistance services, free of charge, are available to you. Call 877-344-7364 (TTY: 711). ATENCIÓN: Si usted habla otros idiomas, tiene a su disposición, gratis, servicios de ayuda para idiomas. Llame al 877-344-7364 (TTY: 711)

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Last Updated 10/1/19

Y0026_ 127364 Accepted 10/1/19