Chapter 34: Dispute Resolution for Medicare Plans

This chapter contains processes for our Medicare members and practitioners to dispute a determination that results in a denial of payment or covered service. To see the dispute resolution process for our other members, view: HIP Medicaid plans. Commercial and HIP Child Health Plus plans.

EmblemHealth provides processes for members and practitioners to dispute a determination that results in a denial of payment and/or covered services. Process, terminology, filing instructions, applicable time frames, and additional and/or external review rights vary based on the type of plan in which the member is enrolled. The processes in this section apply to EmblemHealth Medicare HMO and EmblemHealth Medicare PPO plans, as well as Medicare Part D plans. Integrated Benefits Dual plans include coverage components from both Medicare Advantage and Medicaid managed care. These dual-eligible members have the right to select which dispute process to use. We do not discriminate against practitioners or members or attempt to terminate a practitioner's agreement or disenroll a member for filing a request for dispute resolution. We have interpreter services available to assist members with language and hearing/vision impairments. Payments for Services in Dispute EmblemHealth network practitioners may not seek payment from members for either covered services or services determined by EmblemHealth's Care Management program not to be medically necessary unless the member agrees, in writing and in advance of the service, to such payment as a private patient and the written agreement is placed in the member's medical record. Any practitioner attempting to collect such payment from the member in the absence of such a written agreement does so in breach of the contractual provisions with EmblemHealth. Such breach may be grounds for termination of the practitioner's contract.

The descriptions below provide a general overview of the dispute resolution terminology used with Medicare Advantage plans. Appeal
A request to review any aspect of a claim determination, adverse benefit determination, or an adverse clinical determination denied with regards to medical necessity. Complaint
A request to review an administrative process, service, or quality of care issue NOT pertaining to a medical necessity determination, a benefit determination, or a claims determination. Coverage Determination
A notification sent when a Part D drug is denied. Grievance
A request to review a claim determination NOT pertaining to a medical necessity determination. Certain disputes may be filed as Expedited or Standard depending on the urgency of the patient's condition. Certain disputes may also be filed as Pre-Service or Post-Service depending on the timing of the determination in question. Organization Determination
A notification sent when a health care service, procedure or treatment is denied. Managing Entities
EmblemHealth contracts with separate managing entities to provide care for certain types of medical conditions. In these cases, the designated managing entity will determine the applicable process for filing a dispute. Appointing a Designee
Members wishing to dispute a determination or claim denial may do so themselves or designate a person or practitioner to act on their behalf. To appoint a designee, members must submit by fax or by mail a signed Appointment of Representative (AOR) form or a Power of Attorney form that specifies the individual as an authorized party. Extensions
In certain circumstances, dispute resolution time frames may be extended if permitted by law and requested by the complainant, or if EmblemHealth believes an extension is in the best interest of the member.

Initial Adverse Determinations

• Service does not meet or no longer meets the criteria for medical necessity, based on the information provided to us.
• Service is considered to be experimental or investigational (rare disease).
• Elective non-urgent service requested by an out-of-network provider can be provided by a participating provider, and there is no medical necessity to access an out-of-network provider.
• Service is approved, but the amount, scope or duration is less than requested.
• Service is not a covered benefit under the member's benefit plan.
• Service is a covered benefit under the member's benefit plan, but the member has exhausted the benefit for that service.

The written notice will be sent to the member and provider and will include:

• The description of the action EmblemHealth has taken or intends to take.
• The reasons for the initial adverse determination, including the clinical rationale, if any.
• The member's right to file an appeal, including the member's right to designate a representative to file an appeal on his or her behalf.
• The process and time frame for filing/reviewing an appeal with EmblemHealth, including
  • An explanation that an expedited review of the appeal can be requested if a delay would significantly increase the risk to a member's health.
  • A toll-free number for filing an appeal.

  In the written notice of initial adverse determination to all dual-eligible members, EmblemHealth will provide notice that:

  • A Medicare appeal must be filed within 60 days from the date of the denial.
  • Filing a Medicare appeal means that the member cannot file for a state fair hearing.
  • The member may still file for Medicare appeal after filing for Medicaid appeal, if it is within the appeal review period.

  Retrospective Review Requests

  For retrospective review requests, EmblemHealth must make a decision and provide written notification of the determination. The decision must be made within 30 days of receipt of the necessary information.