| FOR DENIALS BASED ON "NO PRIOR APPROVAL" | ||||
| FOR DENIALS BASED ON "NO E.R. NOTIFICATION" | ||||
BENEFIT PLAN(S): | WHAT/HOW/WHERE TO FILE INSTRUCTIONS: | TIME FRAMES:* | ADDITIONAL RIGHTS: | |
Initial Facility Filing: | EmblemHealth Determination Notification: | |||
HIP Commercial and HIP Child Health Plus | Unless otherwise directed in the denial letter, write to: EmblemHealth Telephone: | 45 calendar days from receipt of remittance statement. | Notification of determination is made within 30 days from receipt of the necessary information. | May file a facility clinical appeal. |
GHI HMO | See Member Appeal. | |||
EmblemHealth PPO/EPO | Unless otherwise directed in the denial letter, write to: EmblemHealth Telephone: | 45 calendar days from receipt of remittance statement. | Notification of determination is made within 30 days from receipt of the necessary information.
| May file a facility clinical appeal. |
* Contracted facility time frames in provider agreements will supersede time frames in this manual.