Table 21-12, Facility Retrospective Review Request

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 Acknowledges Receipt

EmblemHealth Determination Notification

All HIP** and EmblemHealth CompreHealth EPO

Unless otherwise directed in the denial letter, write to:

EmblemHealth 
Grievance and Appeal Dept
PO Box 2844
New York, NY 
10116-2844

Telephone:
1-800-447-8255

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.

       

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:
1-866-447-9717

Fax to:
1-212-287-2754

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.

 

External appeal

Chapter 32 Dispute Resolution for Commercial and CHP Plans