Table 21-1, Practitioner Complaint/Grievance Procedure

BENEFIT PLAN(S):

WHAT/HOW/WHERE TO FILE HARD COPY:**

TIME FRAMES:*

ADDITIONAL RIGHTS:

Initial Practitioner Filing:

EmblemHealth Acknowledges Receipt:

EmblemHealth Determination Notification:

Unless otherwise directed in the denial letter or Explanation of Payment (EOP), write to:

EmblemHealth
Grievance and Appeal Dept
P.O. Box 2844
New York, NY 10116-2844

Telephone:
800-447-8255 (TTY: 711). 

45 calendar days from event.

15 calendar days from receipt of the request.

Complaint: 30 calendar days from receipt of request.

Grievance: 45 
calendar days from receipt of request.

Decision is final.

GHI HMO

Unless otherwise directed in the denial letter or Explanation of Payment (EOP), write to:

GHI HMO
Appeals and Complaints Dept
 P.O. Box 2844
New York, NY 10116-2844

Telephone:
877-244-4466

TDD: 877-208-7920

Fax to: 
845-340-3435

45 calendar days from event.

15 calendar days from receipt of the request.

Complaint: 30 calendar days from receipt of request.

Grievance: 45 
calendar days from receipt of request.

Decision is final.

EmblemHealth EPO/PPO

Unless otherwise directed in the denial letter or Explanation of Payment (EOP), write to:

EmblemHealth
P.O. Box 2844
New York, NY 10116-2844

Telephone:
212-501-4444 (TTY: 711)

45 calendar days from event.

15 calendar days from receipt of the request.

Complaint: 30 calendar days from receipt of request.

Grievance: 45 
calendar days from receipt of request.

Decision is final.