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Medical Policies

Criteria Used for Medical Necessity Decisions

Medical Policies

EmblemHealth uses established policies to make sure medical necessity decisions are consistent with industry standards. The health plan follows the medical policies for the company underwriting or administering the member’s benefit plan. You can see the full list of the guidelines we use on this Medical Policies page.

Site of Service Policies

At EmblemHealth, your health is our highest priority. This means we stay on top of best practices and adopt the ones we believe can help you get and stay healthy in an affordable way. When we find a better way of doing something, we update our policies. Here are our current policies:

Appeal Rights for Site of Service Denials

EmblemHealth respects you and your doctor’s plan for your care. If your request for services in a particular setting is denied by us based on either of these policies, you will receive an adverse determination. You have the right to appeal the denial within 180 days of the date of the adverse determination. The adverse determination will include information about your rights to an appeal, how to file an appeal, and how to get more help.

You can mail or fax your appeal to the addresses or numbers listed below:

Site of Service Medical Policy – Ambulatory Surgery PolicySite of Service Medical Policy – Infusions and Injectables Policy
  • By Phone: 800-447-8255
  • By Mail:
    • EmblemHealth Plan, Inc.
      Grievance and Appeals Unit
      P.O. Box 2844
      New York, NY 10116-2844
  • By Fax:
    • EmblemHealth Plan, Inc.
      Grievance and Appeals Unit&
      212-510-5320
  • By Phone: 888-447-8175
  • By Mail:
    • EmblemHealth Plan, Inc.
      Grievance and Appeals Unit
      P.O. Box 2844
      New York, NY 10116-2844
  • By Fax:
    • EmblemHealth Plan, Inc.
      Grievance and Appeals Unit
      866-350-2168

If the appeal of your adverse determination is denied, you will receive a final adverse determination. You have the right to file an external appeal within four (4) months of the date of the final adverse determination. Instructions and other information you need to file an external appeal will be included in your final adverse determination. You can also find instructions here.