Table 21-11, Appeal - Standard

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.

Chapter 32 Dispute Resolution for Commercial and CHP Plans