Note: If you have a denied behavioral health authorization on file, submit a behavioral health authorization appeal – not a post-claim review request.
Use the instructions in the sections below to submit reviews and appeals requests for behavioral health authorizations for commercial, individual/ACA and Medicaid members. Click on the headings to expand each section.
Note: If you have a denied behavioral health authorization on file, submit a behavioral health authorization appeal – not a post-claim review request.
You received a denial on your prior authorization request and haven't submitted a claim after the service was rendered.
Submit your behavioral health authorization appeal within 65 days of the initial prior authorization denial.
Recommended: Use your prism account as described above. Don't have one? Create one now.
OR
The servicing provider must either complete the Level I appeal form or submit a letter noting the details and services being appealed. Fax completed appeal form or letter to 616.975.0249.
Additional required documentation:
In-network providers and out-of-network providers with a prism account: Your request will appear in the Appeals List page in prism after you click Submit. We'll review the 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 the denial, you have the option of filing a level II behavioral health authorization appeal.
Out-of-network providers without a prism account: We'll make a determination on your level I appeal within 30 calendar days of the submission. We'll inform you of the outcome by fax (if the denial is overturned) or denial letter (if the denial is upheld).
You received a denial on your level I appeal.
Within 30 days of an adverse level I appeal decision.
Recommended: Use your prism account as described above. Don't have one? Create one now.
OR
The servicing provider must complete a Level II appeal form or submit a letter noting the details and services being appealed. Fax completed appeal form or letter to 616.975.0249.
Additional required documentation:
In-network providers and out-of-network providers with a prism account: Your request will appear in the General Request list page in prism after you click Submit. We'll make a determination on your level II appeal within 30 days of receipt. We'll inform you of the outcome of the review either by remittance advice or by adverse determination letter within 5 business days of the decision.
Out-of-network providers without a prism account: We'll make a determination on your level II appeal within 30 days of receipt. We'll inform you of the outcome by fax (if the denial is overturned) or denial letter (if the denial is upheld).
Community Mental Health and Prepaid Inpatient Health Plans are designated as providers of specialized mental health and developmental disability services under contract with the MDHHS. Contact the designated Community Mental Health or Prepaid Inpatient Hospital Plan for specialized behavioral health and appeals.
Submit a retrospective authorization request up to 90 days after a service is rendered. If your request is denied, follow the appeal process outlined below.
If more than 90 days have passed since the service was rendered, you must submit a claim before filing a post-claim level I appeal.
Payer not identified at time of service.
Within 90 days after the service is rendered.
Retrospective authorization requests are submitted through GuidingCare (login required). Out-of-network providers may submit retrospective authorization requests via fax using the appropriate authorization form.
We'll review your request and make the determination. If it’s determined a Peer Review is required with a Medical Director, a call will be scheduled with you. If you’re not satisfied with the outcome, you can file a level I behavioral health authorization appeal.
Authorization denied for inpatient level of care
Within 65 days of the initial authorization denial
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 we uphold the denial, you can file a level II behavioral health authorization appeal.
Within 30 days of a level I appeal denial
Your request will appear in the Appeals List page in prism after you click Submit. After the level II appeal is submitted, we'll 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.