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.