Table 23-3, Appeal - Contracted Facility Clinical Appeal

TABLE 23-3, APPEAL - CONTRACTED FACILITY CLINICAL APPEAL
EMBLEMHEALTH MEDICARE HMO PLANS
BENEFIT PLAN(S)	WHAT/HOW/WHERE TO FILE: INSTRUCTIONS	TIME FRAMES			ADDITIONAL RIGHTS
		Initial Provider* Filing	EmblemHealth Acknowledges Receipt	EmblemHealth Determination Notification
EmblemHealth Medicare HMO Plans	Write to EmblemHealth Medicare HMO PO Box 2807 New York, NY 10116-2844 Telephone: 1-888-447-8255	45 calendar days from receipt of written adverse determination. Exceptions:NY Presbyterian - 365 calendar days from discharge date or 60 calendar days from denial date (whichever is later); Long Island Health Network - 60 calendar days; SUNY Downstate - 120 calendar days.	15 calendar days from receipt of request.	60 calendar days from receipt of request. The provider notified within 2 days of determination.	N/A

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

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