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.

Find a doctor or medical office

myEmblemHealth Member Portal

Language Assistance:

Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.