Table 21-10, Clinical Appeal - Expedited

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.

Chapter 32 Dispute Resolution for Commercial and CHP Plans