Table 23-3, Appeal - Contracted Facility Clinical Appeal

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 
P.O. Box 2844
New York, NY 10116-2844

Telephone:
888-447-8255 (TTY: 711).

60 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.

30 calendar days for pre-service and 60 calendar days for post-service from receipt of request.

The provider notified within two days of determination.

N/A