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 |
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Initial Facility Filing |
EmblemHealth Acknowledges Receipt |
EmblemHealth Determination Notification |
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All HIP** and EmblemHealth CompreHealth EPO |
Unless otherwise directed in the denial letter, write to: EmblemHealth Telephone: |
45 days from the claim denial, unless specified otherwise by your contract with HIP. |
15 calendar days from receipt of necessary information. |
Determination is made within 30 days from receipt of request for retrospective utilization review. |
May file a facility clinical appeal. |
GHI HMO** |
See Member Appeal. |
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GHI PPO** and EmblemHealth PPO/EPO |
Unless otherwise directed in the denial letter, write to: GHI or EmblemHealth Telephone: Fax to: |
Member: 180 calendar days from receipt of written adverse determination. Provider: 45 calendar days from receipt of written adverse determination. |
15 calendar days from receipt of necessary information. |
60 calendar days from receipt. (30 days for PPO accounts) Both member and provider notified within 2 business days of determination.
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External appeal |