An employee is questioning an Empire decision. What should he/she do?
An appeal is an oral or written request to review and change a service authorization decision by Empire stating that the service is not medically necessary or is experimental or investigational. For example, an employee may think Empire should have authorized a certain medical procedure. A grievance is an oral or written request to change an adverse determination that was based on administrative policies, procedures or guidelines. For example, a claim was denied because a member did not obtain precertification for services. To submit an appeal or grievance, your employees should call the Member Services phone number on the back of their Empire identification card, or they can write to the address below with the reason why they believe the coverage request was improperly denied or the claim was improperly paid. They should submit any data to support the request, which should include their member ID number and, if applicable, their claim number and date of service.
