Member Grievance - Second Level Process Tables

TABLE 21-8, SECOND LEVEL MEMBER GRIEVANCE - EXPEDITED

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).

60 business days from receipt of 
written 
grievance determination.

N/A

Within two business days of receipt of necessary information but not to exceed 72 hours.

Verbally at time of determination. Written notice is provided no later than two business days from receipt of all necessary information, or 72 hours from receipt of the 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).

60 business days from receipt of 
written 
grievance determination.

N/A

Within two business days of receipt of necessary information but not to exceed 72 hours.

Verbally at time of determination. Written notice is provided no later than two business days from receipt of all necessary information, or 72 hours from receipt of the 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

Telephone:

212-501-4444 (TTY: 711).

60 business days from receipt of written 
grievance determination.

 N/A

Within two business days of receipt of necessary information but not to exceed 72 hours.

Verbally at time of determination. Written notice is provided no later than two business days from receipt of all necessary information, or 72 hours from receipt of the grievance.

Decision is final.

TABLE 21-9, SECOND LEVEL MEMBER GRIEVANCE - STANDARD

COMMERCIAL AND CHILD HEALTH PLUS PLANS

BENEFIT PLAN(S):

WHAT/HOW/WHERE TO FILE INSTRUCTIONS:

TIME FRAMES:

ADDITIONAL RIGHTS:

Initial 
Practitioner 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).

60 business days from receipt of 
written 
grievance determination.

Pre-Service: Acknowledgement is not required if responded to within 15 calendar days.

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

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

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

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).

60 business days from receipt of 
written 
grievance determination.

Pre-Service: Acknowledgement is not required if responded to within 15 calendar days.

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

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

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

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:
877-842-3625 (TTY: 711).

60 business days from receipt of 
written 
grievance determination.

Pre-Service: Acknowledgement is not required if responded to within 15 calendar days.

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

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

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

Decision is final.