Medicare behavioral health authorization reviews & appeals

Level I authorization appeal

Situation

You received a denial from the initial prior authorization review and haven't submitted a claim for services rendered.

Deadline

Within 65 days from notice of initial prior authorization denial.

Process

1. Log into your prism account.
2. Click the Appeals tab.
3. Click New Pre-Claim Appeal.
4. Choose the most appropriate request type (see below) and enter in the required fields.
   Appeal, pre-claim inpatient emergent: Use when an emergent mental health inpatient authorization has been denied and no claim has been submitted.
   Appeal, pre-claim inpatient elective: Use when inpatient authorizations have been denied pre-service and no claim has been submitted. **DO NOT submit emergent inpatient mental health admissions here. Use for Detox, SUD Residential, Inpatient ECT and Mental Health Residential.
   Appeal, pre-claim outpatient: Use when outpatient behavioral health authorizations have been denied pre-service and no claim has been submitted. Use for TMS, ABA, IOP and Partial Hospitalization.
   
5. Upload clinical documentation to support your appeal.
6. Click Submit.

After submission

Your inquiry will appear in prism within the Appeals list page. Our team will review contractual, benefit claims and medical record information. We'll inform you of the outcome of the review either by remittance advice or by adverse determination letter within 30 calendar days of the submission. If we uphold a pre-claim denial, you may file a level II appeal.

Level II authorization appeal

Situation

You submitted a Level I authorization appeal and received an adverse determination.

Deadline

Within 30 days of a Level I appeal denial

Process

1. Log into your prism account.
2. Click the Appeals tab.
3. Click New Pre-Claim Appeal.
4. Choose the most appropriate request type (see below) and complete the required fields.
   Appeal, pre-claim inpatient emergent: Use when an emergent mental health inpatient authorization has been denied and no claim has been submitted.
   Appeal, pre-claim inpatient elective: Use when inpatient authorizations have been denied pre-service and no claim has been submitted. **DO NOT submit emergent inpatient mental health admissions here. Use for Detox, SUD Residential, Inpatient ECT and Mental Health Residential.
   Appeal, pre-claim outpatient: Use when outpatient behavioral health authorizations have been denied pre-service and no claim has been submitted. Use for TMS, ABA, IOP and Partial Hospitalization.
   
5. Upload supporting documentation to support your appeal.
6. Click Submit.

After submission

Your request will appear in the General Requests page in prism after you click Submit. After the Level II appeal is submitted, our staff will make a determination within 30 days of receipt. We’ll inform you of our decision either by remittance advice or by adverse determination letter within five business days of the decision.

For Priority Health Medicare Advantage members

You may not request a retrospective authorization. Under Part C (Medicare Advantage) rules, once a service has been rendered without obtaining prior authorization it is considered to be post-service even if we have not received a claim. Post-service, you may simply submit a claim to request payment.

If we deny your request for payment

The member has the right to appeal a denial. Note: A contracted provider cannot appeal on behalf of a Priority Health Medicare member. See Reconsideration/appeals under Medicare for more information.

Learn more details about Medicare non-coverage for Medicare Advantage patients.