Procedures for initiating a contracted provider complaint/grievance with respect to an EmblemHealth Medicare member are outlined in the table below.
Table 23-1, Provider Complaint/Grievance Procedures
Practitioner Complaint Procedures
If a practitioner is dissatisfied with an administrative process, quality of care issue, and/or any aspect of service rendered by EmblemHealth that does not pertain to a benefit or claim determination, the practitioner may file a complaint on their own behalf. Examples of such dissatisfaction include:
- Long wait times on EmblemHealth's authorization phone lines.
- Difficulty using EmblemHealth's systems.
- Quality-of-care issues.
Once a decision is made on a practitioner's complaint, it is considered final and there are no additional internal review rights.
Complaints must be submitted in writing to the EmblemHealth's Grievance and Appeals Department. A complaint should include a detailed explanation of the clinician's request and any documentation to support the practitioner's position.
EmblemHealth will acknowledge receipt of the practitioner's complaint in writing no later than 15 days after its receipt. Practitioner complaints will be reviewed, and a written response will be issued directly to the practitioner no later than 30 days after receipt.
Contracted Provider Grievance Process for Medicare HMO and PPO Plans
If a provider is not satisfied with any aspect of a claim determination rendered by EmblemHealth (or any entity designated to perform administrative functions on its behalf) which does not pertain to a medical necessity determination, that provider may file a claim inquiry with EmblemHealth. If the inquiry does not resolve the issue, the provider may then file a grievance.
The provider should use the secure provider portal to submit a claim inquiry along with supporting documentation. To initiate an inquiry, sign in to emblemhealth.com/providers and follow these steps:
1. Select the Claims tab and click Search Claims to locate your claim.
2. On the Claims Detail page, click Ask a Question.
3. On the Message Details page, select Claims and Payments category (and a subcategory) to file a claim inquiry.
4. Enter Message Content and upload Attachments (if necessary) and click Submit.
If the provider is not satisfied with the outcome of the inquiry, they have the option of filing a grievance via the secure provider portal. To submit a grievance, sign in to emblemhealth.com/providers and follow these steps:
1. Click the User Profile icon and select My Messages.
2. On the My Messages page, search and locate the message you submitted for the initial claim inquiry.
3. Click Follow-up to create a linked message.
4. On the Message Details page, select Grievances & Appeals category (and a subcategory) to file a grievance.
5. Enter Message Content and upload Attachments (if necessary) and click Submit.
See the provider portal training guides and videos for step-by-step instructions on using the Message Center and Claims – Search, View, and Export.
The Grievance and Appeals Department is not involved in determining claim payment or authorizing services, but independently investigates all grievances.
Examples of reasons for filing grievances include dissatisfaction with a decision resulting from a failure to follow a plan policy or procedure, or failure to obtain prior approval for an inpatient admission. A provider may also file a grievance regarding how a claim was processed, including issues such as computational errors, interpretation of contract reimbursement terms, or timeliness of payment.
In addition, providers who wish to challenge the recovery of an overpayment or request a reconsideration for claims denied exclusively for untimely filing may follow the grievance procedures in this sub-section.
Note: The right to reconsideration shall not apply to a claim submitted after the time frame outlined in the Timely Submission section of the Claims chapter. If a claim was submitted more than the specified time frame, EmblemHealth may deny the claim in full or may reduce payments by up to 25 percent of the amount that would have been paid had the claim been submitted in a timely manner.
For grievances related to untimely filing, the provider must demonstrate that the late submission was an unusual occurrence and that they have a pattern of submitting claims in a timely manner. Examples of an unusual occurrence include:
- Medicaid Reclamation.
- Member submitted the provider the wrong insurance information.
- Coordination of Benefits related issues.
- Member retroactively reinstated.
The grievance should be accompanied by a copy of the notice of the standard denial or other documentation of the denial, an explanation outlining the details of the request for a review and all documentation to support a reversal of the decision.
EmblemHealth will acknowledge, in writing, receipt of a grievance that is submitted in writing no later than 15 days after its receipt. The grievance will be reviewed, and a written response will be issued for grievances with a final disposition of partial overturn or upheld, no later than 30 days after receipt. The determination included in the response will be final.
Grievances with a favorable disposition will receive a claims remittance advice in lieu of a written response no later than 30 days after receipt.
Notice of Determinations of Grievance Decision
The written Notice of Determination will include the following:
- The date the request was received.
- Detailed reasons for the determination, including the clinical rational if applicable.
- A statement that the notice is a final determination.
- Notice that the member and EmblemHealth will be held harmless.