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.