Table 21-13, Facility Clinical Appeal

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 calendar days from receipt of written adverse determination.

15 calendar days from receipt of necessary information

For members already discharged or "no information" denial:

5 business days from determination.

For no E.R. notification:

Within 2 business days of determination.

60 calendar days.

(30 days for PPO accounts)

Both member and provider notified within 2 business days of 
determination.

GHI HMO

For members already discharged:
This process does not exist for these plans. Please file a member appeal.

For "no information" denial or no E.R. 
notification:
This process does not exist for these plans. Please file a dispute of this type as a practitioner grievance.

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 the claim denial, unless specified otherwise by your contract with HIP.

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