Table 23-2, Facility Retrospective Review Request

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.