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:

HIP Commercial and HIP Child Health Plus

Unless otherwise directed in the denial letter, write to:

EmblemHealth
Grievance and Appeal Dept.
P.O. Box 2844
New York, NY 10116-2844

Telephone:
800-447-8255 (TTY: 711).

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:

Five business days from determination.

For no E.R. notification:

Within two business days of determination.

60 calendar days.

(30 days for PPO accounts)

Both member and provider notified within two 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.

 EmblemHealth PPO/EPO

Unless otherwise directed in the denial letter, write to:

EmblemHealth
Supervisor of Appeals
P.O. Box 2809
New York, NY 10116

Telephone: 
866-447-9717 (TTY: 711).

Fax to: 
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 two business days of 
determination.

External appeal.