TABLE 21-8, SECOND LEVEL MEMBER GRIEVANCE - EXPEDITED |
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COMMERCIAL AND CHILD HEALTH PLUS PLANS |
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BENEFIT PLAN(S) |
WHAT/HOW/WHERE TO FILE: INSTRUCTIONS |
TIME FRAMES |
ADDITIONAL RIGHTS |
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Initial |
EmblemHealth Acknowledges Receipt |
EmblemHealth |
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HIP Commercial, |
Unless otherwise directed in the denial EmblemHealth Telephone: |
60 business days from receipt of |
N/A |
Within 2 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 2 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 1-800-206-8125. |
GHI HMO |
Unless otherwise directed in the denial letter, write to: GHI HMO Telephone: |
60 business days from receipt of |
N/A |
Within 2 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 2 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 1-800-206-8125. |
GHI and EmblemHealth EPO/PPO |
Unless otherwise directed in the denial letter, write to: EmblemHealth/GHI Telephone: |
60 business days from receipt of written |
-- N/A |
Within 2 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 2 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 |
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COMMERCIAL AND CHILD HEALTH PLUS PLANS |
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BENEFIT PLAN(S) |
WHAT/HOW/WHERE TO FILE INSTRUCTIONS |
TIME FRAMES |
ADDITIONAL RIGHTS |
||
Initial |
EmblemHealth Acknowledges Receipt |
EmblemHealth Determination |
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HIP Commercial, HIP Child Health Plus and |
Unless otherwise directed in the denial EmblemHealth Telephone: |
60 business days from receipt of |
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 Post-Service: 30 |
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 Telephone: |
60 business days from receipt of |
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 Post-Service: 30 |
Additional complaints may be filed with the NYS DOH at any time by calling 1-800-206-8125. |
GHI and |
Unless otherwise directed in the denial letter, write to: EmblemHealth/GHI Telephone: |
60 business days from receipt of |
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 Post-Service: 30 |
Decision is final. |