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

TIME FRAMES

ADDITIONAL RIGHTS

Initial 
Member 
Filing

EmblemHealth Acknowledges Receipt

EmblemHealth Determination Notification

HIP Commercial,
HIP Child Health Plus and EmblemHealth CompreHealth EPO (Retired August 1, 2018)

Unless otherwise directed in the denial letter, write to:

EmblemHealth
Grievance and Appeal Dept
PO Box 2844
New York, NY 
10116-2844

Telephone:
1-800-447-8255

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 1-800-206-8125.

GHI HMO

Unless otherwise directed in the denial letter, write to:

GHI HMO
Appeals and 
Complaints Dept
PO Box 2807
New York, NY 10117-2807

Telephone:
1-877-244-4466

TTY/TDD: 711

Fax to: 
1-845-340-3435

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 1-800-206-8125.

GHI and 
EmblemHealth EPO/PPO

Unless otherwise directed in the denial letter, write to:

EmblemHealth/GHI
PO Box 2857
New York, NY 10116

Telephone:
1-212-501-4444

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)

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 and 
EmblemHealth CompreHealth EPO (Retired August 1, 2018)

Unless otherwise directed in the denial 
letter, write to:

EmblemHealth
Grievance and Appeal Dept
PO Box 2844
New York, NY 10116-2844

Telephone:
1-800-447-8255

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 1-800-206-8125.

GHI HMO

Unless otherwise directed in the denial 
letter, write to:

GHI HMO
Appeals and Complaints Dept
PO Box 2807
New York, NY 10117-2807

Telephone:
1-877-244-4466

TTY/TDD: 711

Fax to: 
1-845-340-3435

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 1-800-206-8125.

GHI and EmblemHealth EPO/PPO

Unless otherwise directed in the denial letter, write to:

EmblemHealth/GHI
PO Box 2857
New York, NY 10116

Telephone:
1-212-501-4444

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.

Chapter 32 Dispute Resolution for Commercial and CHP Plans