Medicare post-acute authorization appeals

Situation

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

Process

For Medicare only, pre-service authorization denials use the member appeal process.

To appeal on behalf of the member, complete and submit the Medicare Member Appeal Form, making sure to attach the Medicare Member Appointment of a Representative Form (form CMS-1696).

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, follow the medical authorization appeal process outlined below.

• Level I medical authorization appeal: Request within 65 days of initial decision
• Level II medical authorization appeal: Request within 30 days of level I 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 30 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

Continuing stay denied or stay extended without continuing stay days request

Deadline

Within 65 days of 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 submitted, 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.

Level II authorization appeal

Deadline

Within 30 days of Level I appeal 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 submitted, 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. 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.

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 Acute Rehab/LTACH/SNF/SAR prior authorization/review form by fax to 616.975.8848.

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.