5 - Complaints, Grievances & Appeals

Appeal Communication
If we make a decision favorable to the person filing the
appeal, written notification is sent stating that the denial
decision has been reversed. On the other hand, if we
make a decision that is not favorable, we will provide
written notification that will include the clinical
rationale upon which the appeal determination is
based. The letter will also contain information and rights
regarding any further appeals.
Expedited and pre-service appeal outcomes are also
telephonically relayed to the person filing the appeal.
External Appeals
Based on New York State Department of Insurance
regulations, if services were denied based on medical
necessity or a determination that they are experimental
or investigational, subsequent to an appeal you may
have the right to an external review. You can initiate an
external review using the form Empire will send you
when our final adverse determination is made. Please
note: providers may request external review only when
representing a member on pre-service (prospective)
appeal or themselves on a post-service (retrospective)
appeal.
BEHAVIORAL HEALTHCARE
APPEALS
To request an appeal of an initial behavioral
healthcare medical management decision (level one
determination) rendered by Magellan, please submit
your request in writing to:
Appeals Department
Magellan Behavioral Health
199 Pomeroy Road
Parsippany, NJ 07054
Should a member not be satisfied with the level one
determination, please follow the procedure outlined in
the level-one determination letter.
Send behavioral health related complaints or
grievances not relating to Medical Management
Department appeals to:
Complaints
Magellan Behavioral Health
199 Pomeroy Road
Parsippany, NJ 07054
Or call 1-800-626-3643
For all other behavioral health vendors, please follow
the instructions on the notice of adverse determination.
For information regarding all claims, or claim disputes,
call Empire Provider Services at 1-800-992-BLUE
(1-800-992-2583), Monday – Friday, 8:30 a.m. – 5:00 p.m.
OUR ADDITIONAL
RESPONSIBILITIES
In addition to the previously stated responsibilities,
we will also:
Protect the confidentiality of all parties involved in
the complaint and appeals process
Allow a member to appoint a representative to act on
his/her behalf at any point during the grievance and
appeals process
Include information regarding the next available
level of appeal into all adverse responses to appeals
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