Appeals Process for EmblemHealth Commercial Products
In the event that a patient, patient’s designee or attending physician chooses to appeal an adverse determination of any Commercial Product pre-service request, the decision may be appealed to HCP by following the instructions found in the Determination Letter.
Expedited Appeal decisions will be made within 2 business days of receipt.
Standard Appeal decisions will be made within 30 days of receipt.
Note: An Expedited Appeal is a request to change an adverse determination for which a healthcare provider believes an immediate appeal is warranted and a delay would significantly increase the risk to a member’s health.
Appeals Process for Medicare and Medicaid Products
Medicare and Medicaid products, pre-service denials, and all products’ Concurrent adverse determinations are handled directly by the health plans. Please follow the instructions for the next steps provided in the Determination Letter.
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.
