5 - Complaints, Grievances & Appeals

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may also file expedited level two grievances. Empire will respond to them within 72 hours of receipt of the grievance. Below are time frames for Empire’s response to grievances. Standard Expedited Level One Within 30 calendar days from our receipt of the grievance. Within 72 hours from our receipt of the grievance RECONSIDERATIONS AND APPEALS If the Medical Management Department determines that an admission, extension of the hospital stay, or some other healthcare service is not medically necessary, you may request reconsideration (through the attending physician) or appeal the decision in the ways described in the following sections. Reconsiderations A request for reconsideration can be made by calling or writing to the Medical Management Department, the specific contact information for which will be listed on the denial letter. The hospital or the physician who recommended the admission, the extension of a stay, or other healthcare services can make the request for reconsideration. In addition, the request can be made only: If we deny service prior to or during a member’s medical service, and If the denial is based on issues of medical necessity, and If the decision occurred without our Medical Director discussing the hospitalization or other services with the physician who recommended them. Services that have already been provided are not subject to reconsideration. Level Two Within 30 calendar days from our receipt of the grievance. Within 72 hours from our receipt of the grievance A reconsideration may be filed within seven calendar days of our initial pre-service (prospective) determination by contacting the Case Management Department which rendered the initial denial of service. All reconsideration requests that are received beyond seven calendar days of the initial pre-service denial should be addressed to the Appeals Unit and will be processed as appeals. A request for reconsideration will be reviewed within one business day by the Medical Director who made the initial decision to deny the precertification or the extension of service. The review will include any additional information provided. If the Medical Director who made the initial decision is not available, another Medical Director may act in his or her place. If we uphold our prior decision, written notification will be provided. This notification will include the following: The reasons for the decision, including the clinical rationale Information on how to obtain a copy of the clinical review criteria used in making the decision Instructions on how to initiate an appeal What additional information, if any, must be provided to or obtained by us in order to make a decision on appeal Appeals Appeals are requests to review and change unfavorable clinical decisions (also called adverse determinations) such as when an admission, the extension of a stay or some other healthcare service is determined not to be medically necessary. Expedited Appeals A provider, a patient, a patient’s family or representative, or a hospital may request an urgent/expedited appeal when the denial of coverage involves: Cases involving continued or extended healthcare services Requests for additional services for a patient undergoing a continuing course of treatment Cases in which the member’s physician or healthcare provider believes an immediate appeal is warranted An expedited appeal must be filed within 180 calendar days of the initial unfavorable decision. Appeals filed after that date will not be considered, and you will receive a letter stating that the opportunity to file an appeal has been exhausted. Expedited appeals will be responded to within 72 hours of Empire’s receipt of the necessary information. page 29
For our Administrative Service Only (ASO) line of business, there are no further appeal options after an expedited appeal. For our fully insured lines of business, a level two pre-service or post-service appeal may be filed within 60 business days of a level one expedited denial. Any level two appeals completed after an expedited appeal will be responded to within 60 calendar days. We will provide reasonable access to a Medical Director within one business day of receiving notice of the request for an expedited appeal. Pre-Service (Prospective) Appeals A pre-service appeal is a request to review an unfavorable decision issued prior to or during a service. Empire offers two levels of pre-service appeals for providers: Level one pre-service appeals must be filed within 180 calendar days of the initial adverse determination. Appeals filed after that date will not be considered, and you will receive a letter stating that the opportunity to file an appeal has been exhausted. Level one pre-service appeals will be responded to within 15 calendar days of Empire’s receipt of the appeal request. Level two pre-service appeals must be filed within 60 business days of the level one appeal determination. Appeals filed after that date will not be considered, and you will receive a letter stating that the opportunity to appeal has been exhausted. Level two pre-service appeals will be responded to within 15 calendar days of Empire’s receipt of the appeal request. Post-Service (Retrospective) Appeals A post-service appeal is a request to review an unfavorable decision issued after a service was rendered. Empire offers two levels of post-service appeals for providers: Level one post-service appeals must be filed within 180 calendar days of the initial adverse determination. Appeals filed after that date will not be considered, and you will receive a letter stating that the opportunity to appeal has been exhausted. Level one post-service appeals will be responded to within 30 calendar days of Empire’s receipt of the appeal request. Level two post-service appeals must be filed within 60 business days of the level one appeal determination. Appeals filed after that date will not be considered, and you will receive a letter stating that the opportunity to appeal has been exhausted. Level two post-service appeals will be responded to within 30 calendar days of Empire’s receipt of the appeal request. Below are appeal time frames for fully insured and ASO lines of business: Standard Expedited Level One Pre-Service Within 15 calendar days from the receipt of the appeal request. Post-Service Within 30 calendar days from the receipt of the appeal request. Within 72 hours from the receipt of the appeal request. APPEAL REVIEW PROCESS Level Two Your appeal should be accompanied by a letter stating why the decision is being appealed and why you feel the decision should be overturned. Also include the information necessary to review it, such as the medical record. All appeals are reviewed by a qualified medical professional, with the same or similar specialty as the practitioner rendering the care and who was not involved with the initial determination. Pre-Service Within 15 calendar days from the receipt of the appeal request. Post-Service Within 30 calendar days from the receipt of the appeal request. N/A for ASO accounts. Within 60 calendar days for fully insured accounts. If sufficient documentation to support the reasons for the appeal is not provided, Empire Appeals Department will attempt to request additional documentation or medical records. page 30
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5 - Complaints, Grievances & Appeals

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