| COMMERCIAL AND CHILD HEALTH PLUS PLANS | |||||
| BENEFIT PLAN(S) | WHAT/HOW/ WHERE TO FILE: INSTRUCTIONS |
TIME FRAMES | ADDITIONAL RIGHTS | ||
| Initial Member/Provider* 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: 1-888-447-6855 Fax to: 1-866-350-2168 |
Member: 180 calendar days from receipt of written adverse determination. Provider: Pre-Service on behalf of the member: 180 calendar days from receipt of written adverse determination. |
Expedited determinations are made in less than 15 days. | 2 business days from receipt of all necessary information, but not to exceed 72 hours from receipt of appeal. |
May appeal using our standard appeal process. External appeal process. 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 TDD: 1-877-208-7920 Fax to: 1-845-340-3435 |
Member: 180 calendar days from receipt of written adverse determination. Provider: Pre-Service on behalf of the member 180 calendar days from receipt of written adverse determination. |
Expedited determinations are made in less than 15 days. | 2 business days from receipt of all necessary information, but not to exceed 72 hours from receipt of appeal. | May appeal using our standard appeal process. External appeal process. Additional complaints may be filed with the NYS DOH at any time by calling 1-800-206-8125. |
| GHI PPO and EmblemHealth PPO/EPO |
Unless otherwise directed in the denial letter, write to: GHI or EmblemHealth Supervisor of Appeals PO Box 2809 New York, NY 10116 Telephone: 1-888-906-7668 Fax to: 1-212-287-2754 |
Member: 180 calendar days from receipt of written adverse determination. Provider: Pre-Service on behalf of the member: 180 calendar days from receipt of written adverse determination. |
Expedited determinations are made in less than 15 days. | 2 business days from receipt of all necessary information, but not to exceed 72 hours from receipt of appeal. | May appeal using our standard appeal process. External appeal process |
*Contracted provider time frames in provider agreements will supersede time frames in this manual except in the case of regulatory requirements.
