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:
BENEFIT PLAN(S):	WHAT/HOW/ WHERE TO FILE INSTRUCTIONS:	Initial Member/Provider* Filing:	EmblemHealth Acknowledges Receipt:	EmblemHealth Determination Notification:	ADDITIONAL RIGHTS:
HIP Commercial, HIP Child Health Plus	Unless otherwise directed in the denial letter, write to: EmblemHealth Grievance and Appeal Dept P.O. Box 2844 New York, NY 10116-2844 Telephone: 888-447-6855 (TTY: 711) Fax to: 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.	Two 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 800-206-8125.
GHI HMO	Unless otherwise directed in the denial letter, write to: GHI HMO Appeals and Complaints Dept P.O. Box 2807 New York, NY 10117-2807 Telephone: 877-244-4466 (TTY: 877-208-7920). Fax to: 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.	Two 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 800-206-8125.
EmblemHealth PPO/EPO	Unless otherwise directed in the denial letter, write to: EmblemHealth Supervisor of Appeals PO Box 2809 New York, NY 10116 Telephone: 888-906-7668 (TTY: 711) Fax to: 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.	Two 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.