You have the right to file a grievance (complaint) or an appeal (ask us to review a request again) if you’re dissatisfied with your plan, your provider, or your treatment by EmblemHealth. You can do this yourself or you can ask someone to act on your behalf.
Non-Medicare members: visit the Under 65 Grievances and Appeals page.
The information provided below explains how to file grievances and appeals and how to request coverage decisions and coverage determinations in writing and by phone. It also includes the time frames and requirements when processing these requests and the forms you may use to make your request.
If you have any questions or to request the total exceptions, grievances and appeals received by EmblemHealth, please call:
You can also contact Medicare directly about your health plan or prescription drug plan.
A grievance is any complaint other than one that involves a coverage determination. A grievance can be about issues you have with our health care professionals or EmblemHealth staff, such as:
You or your representative must file a grievance no later than 60 days after the event or incident that caused the grievance. If your request for an expedited coverage decision, reconsideration or coverage redetermination is denied, you can file an expedited grievance.
All grievances can be filed by writing, by phone, or by fax to:
EmblemHealth Medicare HMO Phone: 877-344-7364 (TTY: 711) Fax: 866-854-2763 |
Grievances submitted orally may be answered either orally or in writing unless you ask for a written response. All grievances about quality of care, no matter how the grievance is filed, will be answered in writing.
We will tell you our finding as quickly as needed based upon your health status. This will be no later than 30 days after the date we receive your grievance.
This time period may be extended by up to 14 days if you ask for such an extension. It may also be extended if we can prove it is needed. If we extend the time frame, you will be told immediately.
Expedited grievances will be answered within 24 hours including Part B drugs.
There is more information available about grievances, coverage decisions, coverage determinations and appeals; if you are an EmblemHealth Medicare HMO member, please see Chapter 9 of your Evidence of Coverage.
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.
Expedited Reconsiderations
An expedited request can be filed by a doctor or a member as follows:
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:
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:
When EmblemHealth extends the time frame:
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:
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)
From Oct. 1 to March 31, you can call us from 8 a.m. to 8 p.m., seven days a week. From April 1 to Sept. 30, you can call us from 8 a.m. to 8 p.m., Monday through Saturday.
Expedited Fax: 866-350-2168
Fax is available 24 hours a day, seven days a week
Email: PartDExpeditedMedicareAppeals@emblemhealth.com
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.
A coverage decision is a decision we make about:
For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from the doctor or if your network doctor refers you to a medical specialist.
You can also contact us and ask for a coverage decision if your doctor:
If you want to know if we will cover a health care product or service before you receive it, you can ask us to make a coverage decision for you. We are making a coverage decision for you when we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare.
If you disagree with this coverage decision, you can request an appeal.
For a standard decision:
When you file a fast complaint, we will give you an answer to your complaint within 24 hours. If we do not give you our answer within 3 calendar days (or if there is an extended time period, by the end of that period), you have the right to appeal.
If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 3 calendar days after we received your request. If we extended the time needed to make our decision, we will provide the coverage by the end of that extended period. If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.
You can ask our plan to make a coverage decision on the medical care you are requesting. Based on your health, if you need a quick response, you should ask us to make a "fast decision."
To get a fast decision, you must meet two requirements:
If your doctor tells us that because of your health the request needs a "fast decision" we will automatically agree to give you a fast decision. If you ask for a "fast decision" on your own, without your doctor's support, our plan will decide if your health requires that we give you a fast decision.
A fast decision means we will answer within 24 hours. However, we can take up to 14 more calendar days if we find that some information that may benefit you is missing, or if you need time to get information to us for the review. If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days.
Coverage decisions can be requested by mail, by phone, or by fax to:
EmblemHealth Medicare HMO
ATTN: Utilization Management
55 Water Street
New York, NY 10041-8190
Phone: 877-344-7364 (TTY: 711)
From Oct. 1 to March 31, you can call us from 8 a.m. to 8 p.m., seven days a week. From April 1 to Sept. 30, you can call us from 8 a.m. to 8 p.m., Monday through Saturday.
Fax: 866-215-2928
A coverage determination is a decision by EmblemHealth and it can include the following:
Coverage determinations include EmblemHealth’s decision on a member’s exception request.
Members may ask us for an exception (change a ruling):
For an exception to be reviewed:
Note that certain high-cost drugs may not be eligible for the exception process. All drugs approved under the exception process must meet the meaning of a Part D drug. Also, a provider’s statement does not necessarily mean it will be approved.
A member, his or her representative, or the member’s prescribing doctor or other prescriber may ask for EmblemHealth to expedite a coverage determination when the member or their doctor or other prescriber believes that waiting for a decision under the standard time frame may place the member’s life, health or ability to regain maximum function in serious jeopardy.
You can request a coverage determination by mail, by phone, by fax, by email or online:
Express Scripts
Attn: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571
Phone: 877-920-1470 (TTY: 800-716-3231)
Fax: 877-251-5896
Online: Express Scripts Coverage Determination
For requests for standard coverage determinations:
For requests for expedited coverage determinations:
If the request to expedite the decision is granted EmblemHealth will give notice to the member (and prescribing doctor or another doctor as needed):
We will give prompt oral notice of the denial of the expedited request which explains the following:
We will also send a written notice within three calendar days after oral notice of the denial. Note that expedited coverage determinations are not allowed for payment requests.
EmblemHealth Medicare HMO, PPO and PDP (City of New York)
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To determine if you may need to request a coverage determination or exception, please refer to EmblemHealth’s Part D Formulary.
You can name a relative, friend, advocate, doctor or anyone else to act for you. The individual may already be authorized under state law to act for you such as your power of attorney. The person you name would be your appointed representative.
If you want to give someone permission to act as your appointed representative, you and that person must complete an Appointment of Representative (AOR) form.
You may also use an equivalent written notice to appoint a representative. The AOR form or written notice with the same information that is needed in the AOR should be sent to the addresses in the Appeals section. This information must be included with your grievance (complaint) or appeal (ask us to review a request again) request.
You also have the right to have a lawyer ask for a coverage determination on your behalf. You can contact your own lawyer or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.
Appointment of Representative Form
Find out if you qualify for this service, which is free for EmblemHealth Medicare plan members with Part D prescription drug coverage.
View important plan documents including coverage and costs for medical product and services and prescription drugs.
Health Insurance Plan of Greater New York (HIP) is an HMO plan with a Medicare contract and a HMO D-SNP plan with a Medicare contract and a contract with the New York State Department of Health. Enrollment in HIP depends on contract renewal. HIP is an EmblemHealth company.
Last Updated 10/01/2024
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