Member Grievance - Second Level Process Tables

TABLE 21-8, SECOND 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 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

60 business days from receipt of 
written 
grievance determination.

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
Appeals and Complaints Dept
PO Box 2844
New York, NY 10116-2844

Telephone:
1-877-244-4466

60 business days from receipt of 
written 
grievance determination.

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
PO Box 2844
New York, NY 10116

Telephone:
1-212-501-4444

60 business days from receipt of written 
grievance determination.

-- 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

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 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

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 1-800-206-8125.

GHI HMO

Unless otherwise directed in the denial letter, write to:

GHI HMO
Appeals and Complaints Dept
PO Box 2844
New York, NY 10116-2844

Telephone:
1-877-244-4466

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 1-800-206-8125.

GHI and 
EmblemHealth EPO/PPO

Unless otherwise directed in the denial letter, write to:

EmblemHealth/GHI
PO Box 2844
New York, NY 10116-2844

Telephone:
1-877-842-3625

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.

Chapter 32 Dispute Resolution for Commercial and CHP Plans