What is the process for appealing a denied claim?

When a claim is denied by EmblemHealth, there is a formal appeals process that members can follow. It is important for individuals to be aware of their rights and the steps involved in disputing a denial. To begin the appeal, a member should first review the denial letter to understand the specific reasons for the denial. This letter typically outlines the criteria that were not met and references the policy provisions applicable to the case. Next, the member needs to gather any necessary documentation that supports the appeal, such as medical records, bills, and any relevant correspondence. It is essential to ensure that all information is organized and clearly presented to strengthen the case. Following this, the member can submit a written appeal. The appeal letter should include the policy number, claim number, and a detailed explanation of why the claim should be approved. EmblemHealth typically requires appeals to be submitted within a certain time frame, which is also outlined in the denial letter. Once the appeal is submitted, EmblemHealth will review the case and make a determination. Members should expect to receive a response within a specified period, as stated in their member handbook. For additional details or specific procedures, it may be beneficial to refer to the information available on the EmblemHealth website.