Table 21-11, Appeal - Standard

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	Member: 180 calendar days from receipt of written adverse determination. Provider: Pre-Service on behalf of member: 180 calendar days from receipt of written adverse determination. For Payment: 45 calendar days from receipt of written adverse determination.	15 calendar days from receipt of the appeal	HMO: 30 calendar days from receipt for pre-service requests. PPO/EPO: 30 calendar days for all requests. Both member and provider notified within two business days of determination but not to exceed determination timeframe.	External Appeal Additional complaints may be filed with the NYS DOH at any time by calling 800-206-8125.
GHI HMO	EmblemHealth Grievance and Appeal Dept P.O. Box 2844 New York, NY 10116-2844 Telephone: 877-244-4466. TDD: 877-208-7920. Fax to: 845-340-3435.	Member: 180 calendar days from receipt of written adverse determination. Provider: Pre-Service on behalf of member: 180 calendar days from receipt of written adverse determination. For Payment: 45 calendar days from receipt of written adverse determination..	15 calendar days from receipt of the appeal.	30 calendar days from receipt for pre-service requests. Both member and provider notified within two business days of determination but not to exceed determination timeframe.	External Appeal 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 P.O. Box 2844 New York, NY 10116-2844 Telephone: 888-906-7668. Fax to: 212-287-2754.	Member: 180 calendar days from receipt of written adverse determination. Provider: Pre-Service on behalf of member: 180 calendar days from receipt of written adverse determination. For Payment: 45 calendar days from receipt of written adverse determination.	15 calendar days from receipt of appeal	30 calendar days Both member and provider notified within two business days of determination but not to exceed determination timeframe.	External appeal

*Contracted provider time frames in provider agreements will supersede time frames in this manual.