Appeals Process for EmblemHealth Commercial Products
In the event a member, their designee, or the Healthcare Provider who recommended the service (or item) chooses to appeal an adverse determination, they can appeal to HCP by following the instructions provided in the Initial Adverse Determination letter.
Expedited Appeal decisions will be made within 72 hours of receipt.
Standard Appeal decisions will be made within 30 days of receipt. HCP acknowledges receipt of the appeal within 15 calendar days of receipt.
Please be sure to send the information requested in the Initial Adverse Determination letter (if any), as well as the name and contact information for the person submitting the appeal. In addition, if you have more information that might help us while reviewing our decision, please include it with your appeal request
Note: An Expedited Appeal is a request to change an adverse determination in which the timeframe for making a non-urgent appeal determination could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function. If the request does not meet expedited appeal criteria, it may be treated as a standard appeal.
Appeals Process for Medicare and Medicaid Products
For Medicare and Medicaid products, appeals are handled directly by the Health Plan. Please follow the instructions provided with your Initial Adverse Determination letter for next steps.
Appointment of Representation for Medicare Members
When an appeal request is submitted by someone other than the patient, an Appointment of Representation form must be signed by the patient and submitted via fax or mail at the same time the appeal is requested.
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