Table 23-2, Facility Retrospective Review Request

TABLE 23-2, 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
EmblemHealth Medicare HMO plans	Write to: EmblemHealth Medicare HMO PO Box 2807 New York, NY 10116-2807 Telephone: 1-800-447-8255	45 calendar days from receipt of remittance statement. Exceptions:North Shore - 180 calendar days; SUNY Downstate - 90 calendar days; NY Presbyterian - 365 calendar days from discharge date or 60 calendar days from denial date (whichever is later).	15 calendar days from receipt of necessary information.	30 days from receipt of all information.	May file a facility clinical appeal.

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

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