TABLE 21-6, FIRST LEVEL MEMBER GRIEVANCE - EXPEDITED |
|||||
COMMERCIAL AND CHILD HEALTH PLUS PLANS |
|||||
BENEFIT PLAN(S): |
WHAT/HOW/WHERE TO FILE INSTRUCTIONS: |
TIME FRAMES: |
ADDITIONAL RIGHTS: |
||
Initial |
EmblemHealth Acknowledges Receipt: |
EmblemHealth Determination Notification: |
|||
HIP Commercial, |
Unless otherwise directed in the denial letter, sign in to: emblemhealth.com and use My Messages under username drop-down. Write to: EmblemHealth Telephone: |
180 calendar days from receipt of |
N/A |
No later than 48 hours from receipt of all necessary information but not to exceed 72 hours from receipt of the grievance. Verbally at time of determination. Written notice provided no later than 48 hours from receipt of all necessary information or 72 hours from receipt of the grievance. |
May file a Additional complaints may be filed with the NYS DOH at any time by calling 800-206-8125. |
GHI HMO |
Unless otherwise directed in the denial letter, sign in to: emblemhealth.com and use My Messages under username drop-down. Write to: GHI HMO Telephone: Fax to: |
180 calendar days from receipt of written adverse |
N/A |
No later than 48 hours from receipt of all necessary information but not to exceed 72 hours from receipt of the grievance. Verbally at time of determination. Written notice provided no later than 48 hours from receipt of all necessary information or 72 hours from receipt of the grievance. |
May file a Additional complaints may be filed with the NYS DOH at any time by calling 800-206-8125. |
EmblemHealth EPO/PPO |
Unless otherwise directed in the denial letter, sign in to: emblemhealth.com and use My Messages under username drop-down. Write to: EmblemHealth Telephone: |
180 calendar days from receipt of written adverse |
N/A |
No later than 48 hours from receipt of all necessary information but not to exceed 72 hours from receipt of the grievance. Verbally at time of determination. Written notice provided no later than 48 hours from receipt of all necessary information or 72 hours from receipt of the grievance. |
May file a |
TABLE 21-7, FIRST LEVEL MEMBER GRIEVANCE - STANDARD |
|||||
FOR COMMERCIAL AND CHILD HEALTH PLUS PLANS |
|||||
BENEFIT PLAN(S): |
WHAT/HOW/WHERE TO FILE INSTRUCTIONS: | TIME FRAMES: |
ADDITIONAL RIGHTS: |
||
Initial Member Filing: |
EmblemHealth Acknowledges Receipt: |
EmblemHealth Determination Notification: |
|||
HIP Commercial, |
Unless otherwise directed in the denial Write to: EmblemHealth Telephone: |
180 calendar days from receipt of |
Pre-Service: Acknowledgement is not required if the response is sent by the 15th calendar day of receipt. Post-Service: 15 calendar days from receipt of the grievance. |
Pre-Service: 15 Post-Service: 30 |
May file a Additional complaints may be filed with the NYS DOH at any time by calling 800-206-8125. |
GHI HMO |
Unless otherwise directed in the denial Write to: GHI HMO Telephone: Fax to: |
180 calendar days from receipt of |
*15 business days from receipt of the grievance (post-service). *Acknowledgement is not required if responded to within 15 calendar days |
Pre-Service: 15 calendar days from receipt of the grievance. Post-Service: 30 calendar days from receipt of grievance. |
May file a Additional complaints may be filed with the NYS DOH at any time by calling 800-206-8125. |
EmblemHealth EPO/PPO |
Unless otherwise directed in the denial letter, sign in to: emblemhealth.com and use My Messages under username drop-down. Write to: EmblemHealth Telephone: |
180 calendar days from receipt of |
*15 business days from receipt of the grievance (post-service). *Acknowledgemeat is not required if responded to within 15 calendar days. |
Pre-Service: 15 calendar days from receipt of the grievance. Post-Service: 30 calendar days from receipt of grievance. |
May file a second level grievance. |