The Empire Plan is a unique health insurance plan designed especially for public employees in New York State. Empire Plan benefits include inpatient and outpatient hospital coverage, medical/surgical coverage, Centers of Excellence for transplants, infertility and cancer, home care services, equipment and supplies, mental health and substance abuse coverage and prescription drug coverage.
GEORGE E. PATAKI
GOVERNOR
GOVERNOR
STATE OF NEW YORK
DEPARTMENT OF CIVIL SERVICE
ALBANY, NEW YORK 12239
www.cs.ny.gov
DEPARTMENT OF CIVIL SERVICE
ALBANY, NEW YORK 12239
www.cs.ny.gov
GEORGE C. SINNOTT
COMMISSIONER
DANIEL E. WALL
EXECUTIVE
DEPUTY COMISSIONER
COMMISSIONER
DANIEL E. WALL
EXECUTIVE
DEPUTY COMISSIONER
PA98-12
TO: Health Benefits Administrators of Participating Agencies
FROM: Employee Benefits Division
SUBJECT: Empire Plan Carriers - Current Review and Appeals Procedures
DATE: October 6, 1998
Our Contract Management Unit recently issued Empire Plan Carriers Review and Appeal Procedures, an informational chart providing the appeals process each Empire Plan carrier uses to address enrollee appeals. Legislation recently passed which will affect these procedures. Updated procedures will be issued once they have been finalized.
Contact the carriers with appeals questions.
EMPIRE PLAN CARRIERS: REVIEW AND APPEALS PROCEDURES
| VENDOR | REVIEW TYPE | TIME TO APPEAL | WHO APPEALS | HOW TO FILE | WHO REVIEWS | TIME LIMIT FOR DECISION/RESPONSE | ADDRESS AND TELEPHONE NUMBER |
|---|---|---|---|---|---|---|---|
| EMPIRE BLUECROSS BLUESHIELD (EBCBS) | Utilization Review: Standard Appeal | 60 days following an adverse decision | Enrollee/Authorized representative | Send letter, call or visit Blue Cross. Include additional details of event and supporting documentation relevant to situation; | Health Care Specialist (R.N.) may approve based on new information if medically appropriate. If decision remains upheld, the Health Care Specialist (R.N.) will refer the documentation to a physician of the same or similar specialty as the treating physician for a determination. | Within 30 calander days of receipt of all necessary information; letter of explaination with all relevant data mailed to enrollee within two (2) business days thereafter | Empire BlueCross BlueShield 11 Corporate Woods Blvd. Albany, NY 12211-0815 518-367-0009 1-800-342-9815 (except Alaska) |
| (EBCBS) | Utilization Review: Expediated Appeal* | N/A | Enrollee/Authorized representative | Send letter, call or visit Blue Cross. Include additional details of event and supporting documentation relevant to situation; | Health Care Specialist (R.N.) may approve based on new information if medically appropriate. If decision remains upheld, the Health Care Specialist (R.N.) will refer the documentation to a physician of the same or similar specialty as the treating physician for a determination | Blue Cross notification by telephone to enrollee immediately; written response generated within two (2) business days of the determination. Upon request, the enrollee may discuss details of appeal with a physician; decision within two (2) business days of receipt of all necessary information. | Empire BlueCross BlueShield 11 Corporate Woods Blvd. Albany, NY 12211-0815 518-367-0009 1-800-342-9815 (except Alaska) |
| (EBCBS) | Grievance (Benefit denial reasons other than medical necessity/UR determinations) Standard Appeal | Within 60 days following an adverse decision | Enrollee/Authorized representative | Send letter, call or visit Blue Cross. Include additional details of event and supporting documentation relevant to situation; | Customer Service Representative reviews the information contained in an appeal. Based on certificate language makes benefit determination. When a medical decision is required the appeal is referred to a Health Care Specialist (R.N.) and/or physician for decision | Written response will be sent within 30 days of receipt of all information required to make a determination. Letter to enrollee with all relevant data including specific Empire Plan language, copies of referenced pages from the Plan Certificate if applicable. Within 48 hours of receipt of all information required to make a determination. | Empire BlueCross BlueShield 11 Corporate Woods Blvd. Albany, NY 12211-0815 518-367-0009 1-800-342-9815 (except Alaska) |
| (EBCBS) | Grievance (Benefit denial reasons other than medical necessity/UR determinations): Expediated Appeal | N/A | Enrollee/Authorized representative | Send letter, call or visit Blue Cross. Include additional details of event and supporting documentation relevant to situation; | Customer Service Representative reviews the information contained in an appeal. Based on certificate language makes benefit determination. When a medical decision is required the appeal is referred to a Health Care Specialist (R.N.) and/or physician for decision | Written response will be sent within 30 days of receipt of all information required to make a determination. Letter to enrollee with all relevant data including specific Empire Plan language, copies of referenced pages from the Plan Certificate if applicable. Within 48 hours of receipt of all information required to make a determination. | Empire BlueCross BlueShield 11 Corporate Woods Blvd. Albany, NY 12211-0815 518-367-0009 1-800-342-9815 (except Alaska) |
*NOTE: When the appeal is received relative to a terminal illness, a physician outside of Empire BlueCross BlueShield of the same or similar specialty reviews the medical documentation for determination.
DEFINITIONS
Preauthorized Review: Prior to service being rendered.
Retrospective Review: After service has been rendered.
Utilization Review: As defined by the Managed Care Reform Act of 1996, the process of reviewing health services to determine whether the services are or were medically necessary.
Standard Utilization Appeal: Appeal of adverse determination relative to medical necessity.
Expediated Utilization Appeal: Appeals when a delay would significantly increase the risk to the patient's health; excludes retrospective adverse determinations.
Grievance Dispute: As defined by managed Care Legislation, concerning benefit determination, other than medical necessity.
EMPIRE PLAN CARRIERS: REVIEW AND APPEALS PROCEDURES
| VENDOR | REVIEWS | APPEALS | TIME TO APPEAL | WHO APPEALS | HOW TO FILE | WHO REVIEWS | TIME LIMIT FOR DECISION/RESPONSE | PHONE NUMBER AND ADDRESS |
|---|---|---|---|---|---|---|---|---|
| UnitedHealthcare (UHC) | Pre-Determination | Within 60 days of receipt of notice of denial | Enrollee/Authorized representative/Provider | UHC Pre-Determination form/letter, with supporting documentation | Medical staff, usually a nurse | 5 to 10 business days if information is complete | UHC P.O. Box 1600 Kingston, NY 12402-1600 Tel: (800) 942-4640 | |
| (UHC) | Claim Review: Administrative | Within 60 days of receipt of notice of denial | Enrollee/Authorized representative/Provider | Letter/call/new or additional information | UHC Service Associate | 5 to 10 business days if information is complete | UHC P.O. Box 1600 Kingston, NY 12402-1600 Tel: (800) 942-4640 | |
| (UHC) | Claim Review: Clinical | Within 60 days of receipt of notice of denial | Enrollee/Authorized representative/Provider | Letter/call/new or additional information | UHC Nurse consultant | 5 to 10 business days if information is complete | UHC P.O. Box 1600 Kingston, NY 12402-1600 Tel: (800) 942-4640 | |
| (UHC) | Level 1: Administrative | Within 60 days of receipt of notice of denial | Enrollee/Authorized representative/Provider | Letter/call/new or additional information | UHC Service Associate | 15 days to acknowledge receipt of appeal. Written response within 60 days of receipt of all necessary information. If review cannot be completed in 60 days, UHC will mail notice of delay. | UHC P.O. Box 1600 Kingston, NY 12402-1600 Tel: (800) 942-4640 | |
| (UHC) | Level 1: Clinical | Within 60 days of receipt of notice of denial | Enrollee/Authorized representative/Provider | Letter/call/new or additional information | UHC Medical Director | 15 days to acknowledge receipt of appeal. Written response within 60 days of receipt of all necessary information. If review cannot be completed in 60 days, UHC will mail notice of delay. | UHC P.O. Box 1600 Kingston, NY 12402-1600 Tel: (800) 942-4640 | |
| (UHC) | Level 1: Pre-Determination | Within 60 days of receipt of notice of denial | Enrollee/Authorized representative/Provider | Letter/call/new or additional information | UHC Medical Director | Within 30 days of receipt of all necessary information. If review cannot be completed within 30 days, UHC will mail notice of delay. | UHC P.O. Box 1600 Kingston, NY 12402-1600 Tel: (800) 942-4640 | |
| (UHC) | Level 2: Administrative | Within 60 days of receipt of notice of denial | Enrollee/Authorized representative/Provider | Letter/call/new or additional information | UHC employee with problem-solving authority above that of previous reviewer | Written notice within 30 business days of receipt of all necessary information | UHC P.O. Box 1600 Kingston, NY 12402-1600 Tel: (800) 942-4640 | |
| (UHC) | Level 2: Clinical | Within 60 days of receipt of notice of denial | Enrollee/Authorized representative/Provider | Letter/call/new or additional information | Medical Director not previously involved in the case, or an outside consultant physician specialty matched as appropriate | Written notice within 30 business days of receipt of all necessary information | UHC Central Office Appeals Unit 8GB-B 450 Columbus Blvd. Hartford, CT 06115 Tel: (860) 702-5135 Fax: (860) 702-5088 | |
| (UHC) | Urgent Situation | Within 60 days of receipt of notice of denial | Enrollee/Authorized representative/Provider | Letter/call/new or additional information | Personnel appropriate to the particular case | Within 2 business days of receipt of all necessary information; written notice to follow within 3 business days thereafter | UHC P.O. Box 1600 Kingston, NY 12402-1600 Tel: (800) 942-4640 |
EMPIRE PLAN CARRIERS: REVIEW AND APPEALS PROCEDURES
| VENDOR | REVIEWS | APPEALS | TIME TO APPEAL | WHO APPEALS | HOW TO FILE | WHO REVIEWS </th scope="row"> | TIME LIMIT FOR DECISION/RESPONSE | PHONE NUMBER AND ADDRESS |
|---|---|---|---|---|---|---|---|---|
| HCAP (Home Care Advocacy Program through UnitedHealthcare) | Level 1: Standard | Maximum of 60 days from date of notice of denial | Enrollee/Authorized representative | Letter/call/fax | A specialty-matched physician not involved in the initial review decision* | Within 30 days from receipt of all information necessary; includes written notification | HCAP P.O. Box 10008 Kingston, NY 12402 Tel: (800) 638-9918 Fax: (914) 336-7132 | |
| HCAP (Home Care Advocacy Program through UnitedHealthcare) | Expedited (Urgent) | Maximum of 60 days from date of notice of denial | Enrollee/Authorized representative | Letter/call/fax | A specialty-matched physician not involved in the initial review decision* | Within 2 business days of receipt of all information necessary; written notification within 1 business day of decision | HCAP P.O. Box 10008 Kingston, NY 12402 Tel: (800) 638-9918 Fax: (914) 336-7132 | |
| HCAP (Home Care Advocacy Program through UnitedHealthcare) | Level 2: Standard | Maximum of 60 days from date of notice of denial | Enrollee/Authorized representative | Letter/call/fax | A specialty-matched physician not involved in any prior review decision* | Within 30 days from receipt of all information of all information necessary; includes written notification | HCAP P.O. Box 10008 Kingston, NY 12402 Tel: (800) 638-9918 Fax: (914) 336-7132 |
* A UHC Medical Director or a physician specialty-matched to the particular case (i.e., an Active Physician Review/NSRS [a separate UHC company] clinical peer reviewer).
EMPIRE PLAN CARRIERS: REVIEW AND APPEALS PROCEDURES
| VENDOR | REVIEWS | CATEGORY OF APPEAL | APPEALS | TIME TO APPEAL | WHO APPEALS | HOW TO FILE | WHO REVIEWS | TIME LIMIT FOR DECISION/RESPONSE | PHONE NUMBER AND ADDRESS |
|---|---|---|---|---|---|---|---|---|---|
| MPN | MPN Review | Within 60 days following notice of denial | Enrollee/Authorized Representative/ Provider | Letter/call, with supporting documentation | MPN Clinician | Within 48 hours; postcard acknowledgment | MPN: c/o UHC 505 Boices Lane Kingston, NY 12401 Tel: (914) 382-7926 Fax: (914) 382-7996 | ||
| MPN | MPN Review | Physical therapy, Chiropractic, Occupational Therapy | Level 1: Administrative (such as Late submission) | Within 60 days following notice of denial | Enrollee/Authorized Representative/ Provider | Letter/call, with supporting documentation | MPN Representative not involved in any prior review | Within 48 hours; postcard acknowledgment | MPN: c/o UHC 505 Boices Lane Kingston, NY 12401 Tel: (914) 382-7926 Fax: (914) 382-7996 |
| MPN | MPN Review | Other clinical (MD, DO, DPM) | Level 1: Clinical | Within 60 days following notice of denial | Enrollee/Authorized Representative/ Provider | Letter/call, with supporting documentation | MPN Representative not involved in prior review. Designated Clinical Reviewer (DPM,DO MD) | Within 15 days of receipt of all necessary information | MPN: c/o UHC 505 Boices Lane Kingston, NY 12401 Tel: (914) 382-7926 Fax: (914) 382-7996 |
| MPN | MPN Review | Physical therapy, Chiropractic, Occupational Therapy | Level 2: Same as above | Within 60 days following notice of denial | Enrollee/Authorized Representative/ Provider | Letter/call, with supporting documentation | Administrative Appeals Committee: MPN representatives not involved in any prior review | Within 48 hours; postcard acknowledgment | MPN: c/o UHC 505 Boices Lane Kingston, NY 12401 Tel: (914) 382-7926 Fax: (914) 382-7996 |
| MPN | MPN Review | Other clinical (MD, DO, DPM) | Level 2: Same as above | Within 60 days following notice of denial | Enrollee/Authorized Representative/ Provider | Letter/call, with supporting documentation | Clinical Appeals Committee: 3 Peers in same specialty as Provider; not involved in any prior reviews | Within 30 days of receipt of all necessary information | MPN: c/o UHC 505 Boices Lane Kingston, NY 12401 Tel: (914) 382-7926 Fax: (914) 382-7996 |
EMPIRE PLAN CARRIERS: REVIEW AND APPEALS PROCEDURES
| VENDORS | REVIEWS | APPEALS | TIME TO APPEAL | WHO APPEALS | HOW TO FILE | WHO REVIEWS | TIME LIMIT FOR DECISION/RESPONSE | PHONE NUMBER AND ADDRESS |
|---|---|---|---|---|---|---|---|---|
| ValueOptions (Mental Health/Substance Abuse) | Inquiry (information or action) | No defined limit, except as Plan directs | Enrollee/Authorized representative/Provider | Letter/call | Customer Service Rep. Also, a Supervisor, if appropriate | Usually within 2 business days Within 20 business days | ValueOptions Attn: Customer Service 433 River Street Suite 200 Troy, NY 12180 Tel: (800) 446-3995 | |
| ValueOptions (Mental Health/Substance Abuse) | Complaint (expression of dissatisfaction) | Level 1: Clinical (Certification denial) | Within 60 days of receipt of notice of non-certification | Enrollee/Authorized representative/Provider | Letter/call | A peer advisor (Ph.D. or M.D., depending on licensure of treating professional involved in the case), not previously involved with the original denial | One business day for inpatient; written response within 1 business day thereafter. Two days for outpatient and Alternative Level of Care (ALOC); written response within 2 business days thereafter. | ValueOptions Attn: Customer Service 433 River Street Suite 200 Troy, NY 12180 Tel: (800) 446-3995 |
| ValueOptions (Mental Health/Substance Abuse) | Complaint (expression of dissatisfaction) | Level 1: Administrative | Within 60 days of receipt of notice of prior determination | Enrollee/Authorized representative/Provider | Letter/call | Designated Value Service Operations staff member not previously involved with the case | Within 20 business days of receipt of all necessary information; written response within 1 business day thereafter. | ValueOptions Attn: Customer Service 433 River Street Suite 200 Troy, NY 12180 Tel: (800) 446-3995 |
| ValueOptions (Mental Health/Substance Abuse) | Complaint (expression of dissatisfaction) | Level 2: Clinical | Within 30 days of receipt of notice of Level 1 determination | Enrollee/Authorized representative/Provider | Letter/call | 2 Medical Directors (1 Value and 1 other) and a Value Clinical Manager | Within 10 business days of receipt of all necessary information; written response within 1 business day thereafter. | ValueOptions Attn: Customer Service 433 River Street Suite 200 Troy, NY 12180 Tel: (800) 446-3995 |
| ValueOptions (Mental Health/Substance Abuse) | Complaint (expression of dissatisfaction) | Level 2: Administravtive | Within 60 days of receipt of notice of Level 1 determination | Enrollee/Authorized representative/Provider | Letter/call | Grievance Review panel: Composed of at minimum: 1 Sr. Rep. from Client Relations and 1 from Customer Service, not previously involved in the case. Reps from other specialty areas included as needed. | Within 30 business days of receipt of all necessary information; written response within 5 business days thereafter. | ValueOptions Attn: Customer Service 433 River Street Suite 200 Troy, NY 12180 Tel: (800) 446-3995 |
EMPIRE PLAN CARRIERS: REVIEW AND APPEALS PROCEDURES
| VENDOR | REVIEWS | APPEALS | TIME TO APPEAL | WHO APPEALS | HOW TO FILE | WHO REVIEWS | TIME LIMIT FOR DECISION/RESPONSE | PHONE NUMBER AND ADDRESS |
|---|---|---|---|---|---|---|---|---|
| VALUE Rx | Pharmacist Review | Enrollee/Physician | Letter/call | Clinical review pharmacist | Within 24 hours; same-day response to enrollee or dispensing pharmacist | ValueRx Pharmacy Program Inc. P.O. Box 749 433 River Street Suite 800 Troy, NY 12181 Tel: (800) 964-1888 Fax: (518) 266-2121 | ||
| VALUE Rx | Pharmacist Review | Prior Authorization Appeal: Level 1 | No defined limit | Enrollee/Physician | Letter/call | Clinical review pharmacist | Within 24-48 hours; call and/or a letter sent to enrollee's physician or dispensing pharmacist | Prior Authorization Dept. Same address as above |
| VALUE Rx | Pharmacist Review | Prior Authorization Appeal: Level 2 | No defined limit | Enrollee/Physician | Letter/call | Clinical pharmacist. If denied, appeal is forwarded to CIGNA's Medical Dept. | Within 14 days; letter to enrollee | Prior Authorization Dept. Same address as above |
| VALUE Rx | Pharmacist Review | Generic Appeal: Level 1 | No defined limit | Enrollee/Physician | Generic Appeals form completed by enrollee and physician | Clinical pharmacist, who forwards to an appeal panel: Clinical Program Manager, Clinical Pharmacist, Mail Order Pharmacist | Within 7 business days; letter to physician and enrollee | Prior Authorization Dept. Same address as above |
| VALUE Rx | Pharmacist Review | Generic Appeal: Level 2 | Within 365 days of original denial | Enrollee/Physician | Letter | Generic Appeals Panel | Within 7 days of receipt of all necessary documentation | Prior Authorization Dept. Same address as above |
| VALUE Rx | Pharmacist Review | Generic Appeal: Level 3 | Within 365 days of original denial | ValueRx Clinical Pharmacist sends appeal to CIGNA | The entire folder with a cover letter from the Clinical Pharmacist | Medical Dept. of CIGNA (Connecticutt General Life Insurance Company); physician review | Within 14 days of receipt of all necessary appeal information; CIGNA sends letter to enrollee | ValueRx Pharmacy Program Inc. P.O. Box 749 433 River Street Suite 800 Troy, NY 12181 Tel: (800) 964-1888 Fax: (518) 266-2121 |
| VALUE Rx | Pharmacist Review | High Cost Care Management: Level 1 | No defined limit | Dispensing pharmacist and/or home health care agency and/or physician/enrollee | Letter/call | Clinical review pharmacist | Within 24 hours, call to physician; same day call to home health care agency and letter follow-up within 48 hours to physician and enrollee | ValueRx Pharmacy Program Inc. P.O. Box 749 433 River Street Suite 800 Troy, NY 12181 Tel: (800) 964-1888 Fax: (518) 266-2121 |
| VALUE Rx | Pharmacist Review | High Cost Care Management: Level 2 | No defined limit | Dispensing pharmacist and/or home health care agency and/or physician/enrollee | Letter/call from physician; case summary with supporting documentation | Specialist physician familiar with the proper use of the drug (Physician group in Boston named CORE, INC.) | Within 3 business days; synopsis to Express Script/ValueRx; letter to enrollee, copy to physician | ValueRx Pharmacy Program Inc. P.O. Box 749 433 River Street Suite 800 Troy, NY 12181 Tel: (800) 964-1888 Fax: (518) 266-2121 |
| VALUE Rx | Pharmacist Review | High Cost Care Management: Level 3 | Within 365 days of original denial | Patient/Physician | Letter/Fax, with supporting documentation | Intracorp (an independent group of specialized physicians in Medical Department of CIGNA) | Within 14 business days; follow-up letter to enrollee; copy to physician and ValueRx | ValueRx Pharmacy Program Inc. P.O. Box 749 433 River Street Suite 800 Troy, NY 12181 Tel: (800) 964-1888 Fax: (518) 266-2121 |
HEALTH MAINTENANCE ORGANIZATIONS (HMOs) IN NYSHIP: REVIEW AND APPEALS PROCEDURES
| VENDOR | LEVEL OF COMPLAINT | CATEGORY OF COMPLAINT | APPEALS | TIME TO APPEAL | WHO APPEALS | HOW TO FILE | WHO REVIEWS | TIME LIMIT FOR DECISION/RESPONSE | PHONE NUMBER AND ADDRESS |
|---|---|---|---|---|---|---|---|---|---|
| HMO (23 different plans in 1998) All Comply with Article 49 ans Section 4408-a of the Public Health Law. Each develops its own particular design for compliance.* | Initial Complaint | Urgent/Emergency | | Within 60 days following notice of adverse determination | Member/Provider | Oral/Written | Clinical peer reviewer/other qualified personnel | Within 48 hours | Individual HMO's address and Phone Numbers. |
| Same as above | Initial Complaint | Referral requests and contract benefit disputes | | Within 60 days following notice of adverse determination | Member/Provider | Oral/Written | Clinical peer reviewer/other qualified personnel | Within 30 days | Individual HMO's address and Phone Numbers. |
| Same as above | Initial Complaint | All others | | Within 60 days following notice of adverse determination | Member/Provider | Oral/Written | Clinical peer reviewer/other qualified personnel | Within 45 days | Individual HMO's address and Phone Numbers. |
| Same as above | First Level Appeal | | Urgent/Emergency | Within 60 days following notice of adverse determination | Member/Provider | Oral/Written | Clinical peer reviewer/other qualified personnel | Within 48 hours | Individual HMO's address and Phone Numbers. |
| Same as above | First Level Appeal | | Referral requests and contract benefit disputes | Within 60 days following notice of adverse determination | Member/Provider | Oral/Written | Clinical peer reviewer/other qualified personnel | Within 30 days | Individual HMO's address and Phone Numbers. |
| Same as above | First Level Appeal | | All others | Within 60 days following notice of adverse determination | Member/Provider | Oral/Written | Clinical peer reviewer/other qualified personnel | Within 45 days | Individual HMO's address and Phone Numbers. |
| Same as above | Additional levels areoptional and vary from HMO to HMO | | Urgent/Emergency | Within 60 days following notice of adverse determination | Member/Provider | Oral/Written | Clinical peer reviewer/other qualified personnel | Within 48 hours | Individual HMO's address and Phone Numbers. |
| Same as above | Additional levels areoptional and vary from HMO to HMO | | Referral requests and contract benefit disputes | Within 60 days following notice of adverse determination | Member/Provider | Oral/Written | Clinical peer reviewer/other qualified personnel | Within 30 days | Individual HMO's address and Phone Numbers. |
| Same as above | Additional levels areoptional and vary from HMO to HMO | | All others | Within 60 days following notice of adverse determination | Member/Provider | Oral/Written | Clinical peer reviewer/other qualified personnel | Within 45 days | Individual HMO's address and Phone Numbers. |
*Once all appeal opportunities within an HMO have been exhausted, the member has the right to appeal to the NYS Department of Health and the NYS Insurance Department.