Grievance and Appeal Information

Coverage Decisions for Medical Care

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her 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 is unsure if we will cover a particular medical service or refuses to provide medical care you think that you need. If you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you. We are making a coverage decision for you whenever 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 make an appeal. Generally, for a standard decision, we will give you our answer within 14 days of receiving your request. We can take up to 14 more days (“an extended time period”) under certain circumstances. If we decide to take extra days to make the decision, we will tell you in writing. If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. 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 14 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 14 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. If your health needs a quick response, you should ask us to make a “fast decision.”

To get a fast decision, you must meet two requirements:

• You can get a fast decision only if you are asking for coverage for medical care you have not yet received. You cannot get a fast decision if your request is about payment for medical care you have already received.
• You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

If your doctor tells us that your health 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. If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter (and we will use the standard deadlines instead). This letter will tell you that if your doctor asks for the fast decision, we will automatically give a fast decision. The letter will also tell how you can file a “fast complaint” about our decision to give you a standard decision instead of the fast decision you asked for. A fast decision means we will answer within 72 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 we decide to take extra days, we will tell you in writing. 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 orally or in writing as follows:

EmblemHealth Medicare PPO: ATTN: Utilization Management 55 Water St New York, NY 10041-8190 Phone: 1-866-557-7300 TDD:    1-866-248-0640 Fax:      1-866-215-2928

EmblemHealth Medicare HMO: ATTN: Utilization Management 55 Water St New York, NY 10041-8190 Phone: 1-877-344-7364 TDD:    1-866-248-0640 Fax:      1-866-215-2928

Part D Drug Coverage Determinations

A coverage determination is a decision by EmblemHealth:

• not to give or pay for a Part D drug because the drug is not medically needed, the drug is obtained from an out-of-network pharmacy or the drug is not on EmblemHealth’s drug list;
• failure to provide a coverage determination in a timely manner, when a delay would adversely affect the health of a member
• about an exception request from the tiering structure
• about an exception request for a non-formulary Part D drug
• about the amount of cost sharing for a drug
• about whether a member has satisfied a prior authorization or utilization management requirement.

Coverage determinations include EmblemHealth’s decision on a member’s exception request. Members may request an exception to a plan’s tiered cost-sharing structure or request coverage of a non-formulary drug. In order for an exception to be reviewed, the doctor must give supporting documentation that the formulary drug would not be as useful (or has been ineffective) and/or would have adverse effects. Note that certain high cost drugs may not be eligible for the exception process. All drugs approved under the exception process must meet the definition of a Part D drug. Also, a provider’s statement does not necessarily result in an automatic favorable determination.

A member, his or her representative, or the member’s prescribing physician or other prescriber, may ask for EmblemHealth to expedite a coverage determination when the member or his/her physician 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 calling or sending a request to:

EmblemHealth Medicare HMO: Pharmacy Services 55 Water St New York, NY 10041-8190 Phone: 1-877-344-7364 TDD:    1-866-248-0640 Fax:      1-877-300-9695

EmblemHealth Medicare PPO: Pharmacy Services 55 Water St New York, NY 10041-8190 Phone: 1-866-557-7300 TDD:    1-866-248-0640 Fax:      1-877-300-9695

EmblemHealth Medicare PDP: Pharmacy Services 55 Water St New York, NY 10041-8190 Phone: 1-877-444-7241 TDD:    1-866-248-0640 Fax:      1-877-300-9695

For requests for standard coverage determinations, EmblemHealth will tell the member (and prescribing doctor or other physician as appropriate) of the determination as quickly as possible but no later than 72 hours after receipt of the request for the coverage determination, or for an exceptions request, when the doctor’s supporting statement (if one is provided) is received.

For requests for expedited coverage determinations, written notice of the determination will be provided by EmblemHealth to the member (and prescribing doctor or other physician as appropriate) of the determination within 24 hours of the date of the request or when the doctor’s supporting statement (if one is provided) is received. If the request is granted, EmblemHealth will give notice to the member (and prescribing doctor or other physician as appropriate) within 24 hours of receiving the request (or for an exceptions request in which a non-formulary drug is requested) or within 24 hours of receiving the doctor’s supporting statement. If the expedited request is denied, EmblemHealth will make the determination within 72 hours of request of doctor’s statement and give prompt oral notice of the denial of the expedited request which explains (1) EmblemHealth’s standard process; (2) informs the member of the right to file expedited grievance; (3) informs the member of the right to resubmit the request with a doctor’s supporting documentation; and (4) gives 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. Note that expedited coverage determinations are not allowed for payment requests.

Medicare Prescription Drug Coverage Determination Request Form
Y0026_122931r File and Use 01/02/2012

To determine if you may need to request a coverage determination or exception, please refer to EmblemHealth's Part D Formulary:

2013 EmblemHealth HMO/PPO Drug Formulary Y0026_123210 Accepted 09/09/2012

2013 EmblemHealth PDP Drug Formulary Y0026_123213 Accepted 09/09/2012

Please visit our Additional Pharmacy Information page for more information about EmblemHealth's formulary.

A grievance is any complaint other than one that involves a coverage determination. A grievance can be about administrative issues, such as EmblemHealth staff or doctors’ attitudes and/or their interactions with members. In addition, grievances may include complaints about the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. For example, dissatisfaction with wait times when filling a prescription or the cleanliness or condition of a network pharmacy. A member or their representative must file a grievance no later than 60 days after the event or incident that caused the grievance. If a request to have a coverage decision, coverage determination, reconsideration or coverage re-determination expedited is denied, you can file an expedited grievance.

All grievances can be filed orally or in writing as follows:

EmblemHealth Medicare HMO Attn: Grievance & Appeals PO Box 2807   New York, NY 10116-2807 Phone: 1-877-344-7364 TDD:    1-866-248-0640 Fax:      1-212-510-5320

EmblemHealth Medicare PPO Attn: Grievance & Appeals PO Box 2807   New York, NY 10116-2807 Phone: 1-866-557-7300 TDD:    1-866-248-0640 Fax:      1-212-510-5320

EmblemHealth Medicare PDP Attn: Grievance & Appeals PO Box 2807   New York, NY 10116-2807 Phone: 1-877-444-7241 TDD:    1-866-248-0640 Fax:      1-212-510-5320

Grievances submitted orally may be answered either orally or in writing unless the member asks for a written response. All grievances about quality of care, no matter how the grievance is filed, will be answered to in writing. EmblemHealth will tell the member of its finding based upon the individual’s health status, but no later than 30 days after the date EmblemHealth gets the grievance. This time period may be extended by up to 14 days if the member asks for such an extension or EmblemHealth can prove the need. If EmblemHealth extends the time frame, the member will be told immediately. Expedited grievances will be answered within 24 hours.

Reconsiderations

A reconsideration is a request from a member, their designee or non-contracted provider to reverse or modify an initial determination to deny, reduce or discontinue services or the denial of payment for medical care. The time frame for filing a reconsideration is 60 calendar days from the date of the notice of the adverse determination. This may be extended if the member shows good cause (this must be in writing and give the reason that it was not filed timely).

For reconsiderations for services that have not been rendered yet (pre-service reconsiderations), EmblemHealth must make its reconsidered determination as quickly as the member’s health condition requires, but no later than 30 calendar days from the date we receive the request for a standard reconsideration. The time frame will be extended by up to 14 calendar days by EmblemHealth if the member requests the extension, or also may be extended by up to 14 calendar days if EmblemHealth justifies a need for additional information and documents how the delay is in the best interest of the member. When EmblemHealth extends the time frame, it must notify the member in writing of the reasons for the delay, and inform the member of the right to file an expedited grievance if he or she disagrees with EmblemHealth’s decision to grant itself an extension. For reconsiderations for a request for reimbursement (services that have already been received and you have paid for), EmblemHealth must make its reconsidered determination no later than 60 calendar days from the date we receive the request.

Standard reconsiderations can be filed orally or in writing as follows:

EmblemHealth Medicare HMO Attn: Grievance & Appeals PO Box 2807   New York, NY 10116-2807 Phone: 1-877-344-7364 TDD:    1-866-248-0640 Fax:      1-212-510-5320

EmblemHealth Medicare PPO Attn: Grievance & Appeals PO Box 2807   New York, NY 10116-2807 Phone: 1-866-557-7300 TDD:    1-866-248-0640 Fax:      1-212-510-5320

Part D Coverage Redeterminations

A coverage redetermination is a request to have an unfavorable coverage determination reviewed or reconsidered for Part D. This includes decisions made by the plan about coverage of a Part D benefit or what amount the plan will pay for a drug. A member, their authorized representative, or the provider acting on the member’s behalf must file their request for a redetermination within 60 calendar days of the date of the notice of the coverage determination. This may be extended if the member shows good cause (this must be in writing and give the reason that it was not filed timely).

For a standard redetermination, EmblemHealth will make the determination and give notice within 7 calendar days of receiving the request. If we approve a request for coverage, we must authorize the drug as quickly as your health requires, but no later than 7 calendar days after we receive your request for redetermination. If we approve your request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your redetermination request.

Standard coverage redetermination requests can be filed orally or in writing as follows:

EmblemHealth Medicare HMO Attn: Grievance & Appeals PO Box 2807   New York, NY 10116-2807 Phone: 1-877-344-7364 TDD:    1-866-248-0640 Fax:      1-212-510-5320

EmblemHealth Medicare PPO Attn: Grievance & Appeals PO Box 2807   New York, NY 10116-2807 Phone: 1-866-557-7300 TDD:    1-866-248-0640 Fax:      1-212-510-5320

EmblemHealth Medicare PDP Attn: Grievance & Appeals PO Box 2807   New York, NY 10116-2807 Phone: 1-877-444-7241 TDD:    1-866-248-0640 Fax:      1-212-510-5320

Medicare Prescription Drug Coverage Redetermination Request Form
Y0026_122930 File and Use 12/27/2011