Member Complaint - First Level Process Tables

Download the Chapter

Return to Provider Manual

Search the Provider Manual

TABLE 21-2, FIRST LEVEL MEMBER COMPLAINT - EXPEDITED
COMMERCIAL AND CHILD HEALTH PLUS PLANS
BENEFIT PLAN(S):	WHAT/HOW/WHERE TO FILE INSTRUCTIONS:	TIME FRAMES:			ADDITIONAL RIGHTS:
BENEFIT PLAN(S):	WHAT/HOW/WHERE TO FILE INSTRUCTIONS:	Initial Member Filing.	EmblemHealth Acknowledges Receipt.	EmblemHealth Determination Notification.	ADDITIONAL RIGHTS:
HIP Commercial, HIP Child Health Plus	Sign in to: emblemhealth.com and use My Messages under username drop-down. Write to: EmblemHealth Grievance and Appeal Dept P.O. Box 2844 New York, NY 10116-2844 Telephone: 800-447-8255 (TTY: 711).	60 business days from event.	N/A	Verbal response within 48 hours of receipt of necessary information. Written notice sent within 3 business days of determination	May file a second level complaint, expedited or standard. Additional complaint may be filed with the NYS DOH at any time by calling 800-206-8125.
GHI HMO	Sign in to: emblemhealth.com and use My Messages under username drop-down. Write to: GHI HMO Appeals and Complaints Dept P.O. Box 22844 New York, NY 10116-2844 Telephone: 877-244-4466 (TTY: 711). Fax to: 845-340-3435	60 calendar days from event.	N/A	Verbal response within 48 hours of receipt of necessary information. Written notice sent within three business days of determination.	May file a second level complaint, expedited or standard Additional complaint may be filed with the NYS DOH at any time by calling 800-206-8125.
EmblemHealth EPO/PPO	Sign in to: emblemhealth.com and use My Messages under username drop-down. Write to: EmblemHealth P.O. Box 2844 New York, NY 10116-2844 Telephone: 212-501-4444 (TTY: 711).	60 calendar days from event.	N/A	Verbal response within 48 hours of receipt of necessary information Written notice sent within three business .	May file a second level complaint, expedited, or standard.

TABLE 21-3, FIRST LEVEL MEMBER COMPLAINT - STANDARD
COMMERCIAL AND CHILD HEALTH PLUS PLANS
BENEFIT PLAN(S):	WHAT/HOW/WHERE TO FILE INSTRUCTIONS:	TIME FRAMES			ADDITIONAL RIGHTS:
BENEFIT PLAN(S):	WHAT/HOW/WHERE TO FILE INSTRUCTIONS:	Initial Member Filing:	EmblemHealth Acknowledges Receipt:	EmblemHealth Determination Notification:	ADDITIONAL RIGHTS:
HIP Commercial,HIP Child Health Plus	Sign in to: emblemhealth.com and use My Messages under username drop-down. Write to: EmblemHealth Grievance and Appeal Dept P.O. Box 2844 New York, NY 10116-2844 Telephone: 800-447-8255 (TTY: 711).	60 business days from event.	15 business days from the receipt of the request	45 calendar days from receipt of all necessary information.	May file a second level complaint. Additional complaint may be filed with the NYS DOH at any time by calling 800-206-8125.
GHI HMO	Sign in to: emblemhealth.com and use My Messages under username drop-down. Write to: GHI HMO Appeals and Complaints Dept P.O. Box 2844 New York, NY 10116-2844 Telephone: 877-244-4466 (TTY: 711) Fax to: 845-340-3435	60 calendar days from event.	15 business days from the receipt of the request	45 calendar days from receipt of all necessary information.	May file a second level complaint. Additional complaint may be filed with the NYS DOH at any time by calling 800-206-8125.
EmblemHealth EPO/PPO	Sign in to: emblemhealth.com and use My Messages under username drop-down Write to: EmblemHealth P.O. Box 2844 New York, NY 10116-2844 Telephone: 212-501-4444 (TTY: 711).	60 calendar days from event.	15 business days from the receipt of the request	45 calendar days from receipt of all necessary information.	May file a second level complaint.