Medicare acute inpatient authorization appeals

In-network providers:

Retrospective authorizations

Situation

Payer not identified at the time of service

Deadline

You can submit a retrospective authorization request up to 90 days after a service is rendered. If your retrospective authorization request is denied, you have one appeal right, to be submitted within 65 days of the denial. If more than 90 days have passed since the service was rendered, you must submit a claim before following the post-claim appeal process. 

Process

Retrospective prior authorization requests are submitted through GuidingCare.

After submission

After submission, our staff will make a determination within 14 days of the request. If you're not satisfied with the outcome, you can file a Level I authorization appeal as outlined below.

Level I authorization appeal

Situation

Authorization denied for acute inpatient level of care

Deadline

Submit your Level I authorization appeal within 65 days of the initial decision.

Process

1. Log into your prism account.
2. Click the Appeals tab.
3. Click New Pre-Claim Appeal or New Post-Claim Appeal*.
   *If a claim has been filed, you must select New Post-Claim Appeal.
   
4. Choose the most appropriate request type and complete the required fields, uploading supporting documentation.
5. Click Submit.

After submission

Your request will appear in the Appeals List page in prism after you click Submit. We’ll inform you of our decision either by remittance advice or adverse determination letter within 30 calendar days of the submission. If Priority Health Medicare renders a partial or fully adverse decision, we automatically send your appeal to MAXIMUS Federal Services. This is Medicare's Independent Review Entity (IRE).  They will review the appeal within 60 calendar days to make sure the correct decision was made. You will receive correspondence by mail regarding their decision. If the IRE renders a favorable decision for you, Priority Health Medicare must effectuate and comply with the IRE's decision. A new Remittance Advice will be sent to reflect the IRE's decision. 

For more information on Part C requirements for Provider Claim Appeals see section 50.1.1.

Out-of-network providers:

Retrospective authorization requests

Situation

Payer not identified at the time of service

Deadline

You can submit a retrospective authorization request up to 90 days after a service is rendered. If your retrospective authorization request is denied, follow our non-contracted provider post-service appeals process.

Process

Submit an Emergent Inpatient Authorization Request form by fax to 616.975.8858.

After submission

After submission, our staff will make a determination within 30 days of the request. If you're not satisfied with the outcome, you can follow the appeal process linked below.

Authorization appeals

Follow our non-contracted provider post-service appeals process.