Member Grievance - First Level Process Tables

TABLE 21-6, FIRST LEVEL MEMBER GRIEVANCE - EXPEDITED

COMMERCIAL AND CHILD HEALTH PLUS PLANS

BENEFIT PLAN(S):

WHAT/HOW/WHERE TO FILE INSTRUCTIONS:

TIME FRAMES:

ADDITIONAL RIGHTS:

Initial 
Member 
Filing:

EmblemHealth Acknowledges Receipt:

EmblemHealth Determination Notification:

HIP Commercial,
HIP Child Health Plus 

Unless otherwise directed in the denial letter, 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).

180 calendar days from receipt of 
written adverse 
determination.

N/A

No later than 48 hours from receipt of all necessary information but not to exceed 72 hours from receipt of the grievance.

Verbally at time of determination.

Written notice provided no later than 48 hours from receipt of all necessary information or 72 hours from receipt of the grievance.

May file a 
second level grievance.

Additional complaints may be filed with the NYS DOH at any time by calling 800-206-8125.

GHI HMO

Unless otherwise directed in the denial letter, 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

180 calendar days from receipt of written adverse 
determination.

N/A

No later than 48 hours from receipt of all necessary information but not to exceed 72 hours from receipt of the grievance.

Verbally at time of determination.

Written notice provided no later than 48 hours from receipt of all necessary information or 72 hours from receipt of the grievance.

May file a 
second level grievance.

Additional complaints may be filed with the NYS DOH at any time by calling 800-206-8125.

EmblemHealth EPO/PPO

Unless otherwise directed in the denial letter, 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).

180 calendar days from receipt of written adverse 
determination.

N/A

No later than 48 hours from receipt of all necessary information but not to exceed 72 hours from receipt of the grievance.

Verbally at time of determination.

Written notice provided no later than 48 hours from receipt of all necessary information or 72 hours from receipt of the grievance.

May file a 
second level grievance.

TABLE 21-7, FIRST LEVEL MEMBER GRIEVANCE - STANDARD

FOR COMMERCIAL AND CHILD HEALTH PLUS PLANS

BENEFIT PLAN(S):

TIME FRAMES:

ADDITIONAL RIGHTS:

Initial Member Filing:

EmblemHealth Acknowledges Receipt:

EmblemHealth Determination Notification:

HIP Commercial,
HIP Child Health Plus 

Unless otherwise directed in the denial 
letter, 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).

180 calendar days from receipt of 
written adverse determination.

Pre-Service: Acknowledgement is not required if the response is sent by the 15th calendar day of receipt.

Post-Service: 15 calendar days from receipt of the grievance.

Pre-Service: 15 
calendar days from receipt of the grievance.

Post-Service: 30 
calendar days from receipt of grievance.

May file a 
second level grievance.

Additional complaints may be filed with the NYS DOH at any time by calling 800-206-8125.

GHI HMO

Unless otherwise directed in the denial 
letter, 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

180 calendar days from receipt of 
written adverse determination.

*15 business days from receipt of the grievance (post-service).

*Acknowledgement is not required if responded to within 15 calendar days

Pre-Service: 15 calendar days from receipt of the grievance.

Post-Service: 30 calendar days from receipt of grievance.

May file a 
second level grievance

Additional complaints may be filed with the NYS DOH at any time by calling 800-206-8125.

EmblemHealth EPO/PPO

Unless otherwise directed in the denial letter, 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)

180 calendar days from receipt of 
written adverse determination.

*15 business days from receipt of the grievance (post-service).

*Acknowledgemeat is not required if responded to within 15 calendar days.

Pre-Service: 15 calendar days from receipt of the grievance.

Post-Service: 30 calendar days from receipt of grievance.

May file a second level grievance.