Table 23-1, Provider Complaint/Grievance Procedures

TABLE 23-1, PROVIDER COMPLAINT/GRIEVANCE PROCEDURES
EMBLEMHEALTH MEDICARE HMO AND PPO PLANS

BENEFIT PLAN(S)

WHAT/HOW/WHERE TO FILE HARD COPY **:

INSTRUCTIONS

TIME FRAMES*

ADDITIONAL RIGHTS

Initial 
Practitioner Filing

EmblemHealth Acknowledges Receipt

EmblemHealth Determination Notification

EmblemHealth Medicare HMO Plans

Sign in to: www.emblemhealth.com.

Write to:
EmblemHealth
Medicare HMO
P.O. Box 2807
New York, NY 10116-2807

45 calendar days from event. Exceptions:SUNY Downstate - 90 calendar days from event; Stony Brook Affiliations - 120 calendar days from event.

15 calendar days from receipt of request.

Complaint: 30 calendar days from receipt of request.

Grievance: 45 calendar days from receipt of request.

Decision is final.

EmblemHealth Medicare PPO Plans

Sign in to: www.emblemhealth.com.

Write to:
EmblemHealth
Medicare PPO
PO Box 2807
New York, NY 10116-2807

45 calendar days from event.

15 calendar days from receipt of request.

Complaint: 30 calendar days from receipt of request.

Grievance: 45 calendar days from receipt of request.

Decision is final.

* Contracted facility time frames in provider agreements will supersede time frames in this manual.