| 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 |
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EmblemHealth Medicare HMO Plans |
Write to EmblemHealth Telephone: |
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.
