Medicare elective inpatient authorization appeals

Use the instructions in the sections below to submit appeals for elective inpatient medical authorizations for Medicare members. Click on the headings to expand each section.

Page last updated on: 6/20/25

Note: If you have a denied elective inpatient medical authorization on file, submit a medical authorization appeal before performing the service – not a post-claim review request. Effective June 2, 2025, we won't review these cases post-claim for medical necessity when a denied authorization is on file.

Pre-service

Situation

You received a denial from the initial prior authorization review and haven't yet performed the requested service.

Deadline

Submit your medical authorization appeal within 65 days from notice of initial determination.

Process

Prism:

  1. Log into your prism account.
  2. Click the Appeals tab.
  3. Click New Pre-Claim Appeal.
  4. Choose the most appropriate request type and enter in the required fields. Upload clinical documentation to support your appeal.
  5. Click Submit.

Mail or fax:

You can also submit via mail or fax to:

Priority Health Medicare Appeals
1231 E. Beltline Ave NE
MS 1150
Grand Rapids, MI 49525

Fax: 616.975.8827

After submission

Your inquiry will appear in prism within the Appeals list page. Our team will review and decision your appeal within 30 calendar days or 72-hours for expedited appeals. You’ll either receive an electronic message of the decision through prism, or we’ll notify you via call or fax.

If we deny your appeal either in part or in full, we automatically send your appeal to MAXIMUS Federal Services. This is Medicare’s Independent Review Entity (IRE). You’ll receive correspondence by mail regarding their decision.

Post-service / pre-claim

No retrospective authorization requests

Situation

The elective admission service took place, and the member was discharged. There is no claim submitted, and now it’s after the service.

Process

Medicare doesn't allow retrospective reviews. Instead, follow this process:

  1. Submit your claim within 12 months of the date of service.
  2. If your claim is denied, follow the post-claim appeal process.

Post-claim

Situation

The procedure has taken place. You don't have an authorization request on file, and you've submitted a claim, which denied due to lack of prior authorization.

Note: Effective June 2, 2025, we won't review cases post-claim for medical necessity when a denied authorization is on file. If you have a denied elective inpatient medical authorization request and wish to appeal, you must do so before performing the service, following the Pre-Service instructions outlined above.

Deadline

File post-claim appeals within 180 calendar days from the claim denial.

Process

Follow the post-claim appeal process.