| 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 |
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 60 calendar days from receipt of request for post service requests PPO/EPO: 30 calendar days for all requests Both member and provider notified within 2 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 1-800-206-8125 |
| GHI HMO
|
EmblemHealth Grievance and Appeal Dept PO Box 2844 New York, NY 10116-2844 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 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 60 calendar days from receipt of request for post service requests Both member and provider notified within 2 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 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 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 2 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.
