If you, your representative or your prescriber feel the standard time frame for an appeal (ask us to review the request again or a coverage redetermination) could seriously risk the member’s life, health, or ability to get back maximum function, you can ask for an expedited appeal.
An expedited request can be filed by a doctor or a member as follows:
- For requests filed by a doctor or by a member with a letter from the doctor requesting an expedited appeal: If the request for an expedited reconsideration is made or supported by a doctor, we must grant the expedited reconsideration request. This means the doctor states that the life or health of the member, or the member’s ability to regain maximum function, could be seriously jeopardized by using the standard time frame.
- For requests filed by the member without a letter from the doctor requesting an expedited appeal: If the request is not supported by a doctor, we will determine if the life or health of the member, or the member’s ability to regain maximum function, could be seriously jeopardized by using the standard time frame in the processing of the reconsideration request.
If we deny a request for an expedited reconsideration, we must transfer the request to the standard reconsideration process. You cannot request an expedited appeal if you are asking us to pay you back for a Part B drug you’ve already received. Payment appeals will fall under the standard reconsideration process. We will make a determination as quickly as the member’s health condition requires.
The reconsideration will be no later than 30 calendar days from the date we received the request. We must also provide the member with prompt oral notice that we will process as standard appeal along with the member’s rights.
We also must mail a notice to the member within three calendar days of the oral notification, which explains the following:
- The request will be processed using the 30-day time frame for standard reconsiderations.
- The right to file an expedited grievance if the member disagrees with the organization’s decision not to expedite the reconsideration.
- Instructions about the grievance process and its time frames.
- The right to resubmit a request for an expedited reconsideration.
- If the member gets any doctor’s support showing that using the standard time frame for making a determination could seriously jeopardize the member’s life, health or ability to regain maximum function, the request will be expedited automatically.
How We Will Process Your Expedited Appeal
If we process your reconsideration as expedited, we must make a decision and give the member (and the doctor involved, as needed) notice of our reconsideration as quickly as the member’s health condition requires. This will be no later than 72 hours after receiving the request.
We may notify the member orally or in writing. We must notify the member within the 72-hour time frame. We will notify the member orally first and then mail written confirmation to the member within three calendar days.
The 72-hour time frame for requests for items and services may be extended by up to 14 calendar days. Part B drug timeframes cannot be extended:
- If the member requests the extension.
- If EmblemHealth finds a need for additional information and documents how the extension is in the interest of the member.
When EmblemHealth extends the time frame:
- We must notify the member in writing of the reasons for the extension.
- Inform the member of the right to file an expedited grievance if the member disagrees with EmblemHealth’s decision to grant an extension.
- We must notify the member of our determination as quickly as the member’s health condition requires, but no later than the last day of the extension.
Expedited Part D Coverage Redeterminations
For expedited redeterminations, a member or their prescribing doctor or other doctor may make an oral or written request for coverage. EmblemHealth will decide if the request should be sped up. Note that expedited redeterminations are not allowed for payment requests. If the request to expedite a coverage redetermination is granted, EmblemHealth will make the determination and give notice within 72 hours of receiving the request. If more medical information is needed, the member and prescribing doctor or another doctor will be told immediately. If the request doesn’t meet expedited criteria, EmblemHealth will notify the member promptly and make a decision within seven days.
The notice to the member that the request doesn’t meet expedited criteria will include the following:
- An explanation of the standard process.
- The member’s right to file an expedited grievance.
- The member’s right to resubmit the request with the doctor’s supporting documentation.
- Instructions about EmblemHealth’s grievance process and its time frames.
We will also send a written notice within three calendar days after oral notice of the denial.
Expedited appeals can be filed by mail, by phone, by fax, or by email to:
EmblemHealth Medicare HMO
Attn: Grievance & Appeals
PO Box 2807
New York, NY 10116-2807
Expedited Phone: 877-344-7364 (TTY: 711)
Monday through Sunday, from 8 am to 8pm
Expedited Fax: 866-350-2168
Fax is available 24 hours a day, seven days a week
The fastest way to get us your expedited appeal is by phone, fax, or email.
More information about grievances, coverage decisions, coverage determinations and appeals is available. If you are an EmblemHealth Medicare HMO member, please see Chapter 9 of your Evidence of Coverage.