| 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 Telephone: |
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.
