Table 21-12, Facility Retrospective Review Request

FOR DENIALS BASED ON "NO PRIOR APPROVAL"
FOR DENIALS BASED ON "NO E.R. NOTIFICATION"
BENEFIT PLAN(S):	WHAT/HOW/WHERE TO FILE INSTRUCTIONS:	TIME FRAMES:*		ADDITIONAL RIGHTS:
BENEFIT PLAN(S):	WHAT/HOW/WHERE TO FILE INSTRUCTIONS:	Initial Facility Filing:	EmblemHealth Determination Notification:	ADDITIONAL RIGHTS:
HIP Commercial and HIP Child Health Plus	Unless otherwise directed in the denial letter, write to: EmblemHealth Grievance and Appeal Dept P.O. Box 2844 New York, NY 10116-2844 Telephone: 866-447-9717 (TTY: 711).	45 calendar days from receipt of remittance statement.	Notification of determination is made within 30 days from receipt of the necessary information.	May file a facility clinical appeal.
GHI HMO	See Member Appeal.
EmblemHealth PPO/EPO	Unless otherwise directed in the denial letter, write to: EmblemHealth Supervisor of Appeals P.O. Box 2809 New York, NY 10116 Telephone: 866-447-9717 (TTY: 711).	45 calendar days from receipt of remittance statement.	Notification of determination is made within 30 days from receipt of the necessary information.	May file a facility clinical appeal.

* Contracted facility time frames in provider agreements will supersede time frames in this manual.