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 Determination Notification:
EmblemHealth Medicare HMO plans	Unless otherwise directed in the denial letter, write to: EmblemHealth Medicare HMO P.O. Box 2807 New York, NY 10116-2807 Telephone: 866-447-9717 (TTY: 711).	45 calendar days from receipt of remittance statement.	Notification of determination is made within 30 days from receipt of the necessary information.	May file a facility clinical appeal.

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