| 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 |
Unless otherwise directed in the denial letter, write to:
|
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 Fax to: |
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: Fax to: |
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.