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 for medical necessity post-claim when a denied authorization is on file.
Non-Medicare elective inpatient authorization appeals
Use the instructions in the sections below to submit appeals for elective inpatient medical authorizations for commercial, individual/ACA and Medicaid members. Click on the headings to expand each section.
Page last updated on: 6/20/25
Pre-service for elective inpatient
Pre-service for elective inpatient
Level I medical authorization appeal
Situation
You received a denial on your prior authorization request and haven't yet performed the service.
Deadline
Submit your medical authorization appeal within 65 days of the initial decision.
Process
- Log into your prism account.
- Click the Appeals tab.
- Click New Pre-Claim Appeal.
- Choose the most appropriate request type and complete the required fields, uploading supporting documentation.
- 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 by adverse determination letter within 30 calendar days of submission. If we uphold the denial, you have the option of filing a Level II medical authorization appeal.
Level II medical authorization appeal
Situation
You received a denial on your Level I appeal.
Deadline
Submit your level II appeal within 30 days of an adverse level I appeal decision
Process
- Log into your prism account.
- Click the Appeals tab.
- Click New Pre-Claim Appeal.
- Choose the most appropriate request type and complete the required fields, uploading supporting documentation.
- 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, 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.
Post-service / pre-claim
Post-service/pre-claim for elective inpatient
Post-service/pre-claim for elective inpatient
Retrospective authorization requests
You have 90 days after the service is rendered to submit a retrospective authorization request.
If more than 90 days have passed since the service was rendered, you must submit a claim and follow the post-claim appeal process.
Situation
You rendered a service that required a prior authorization but failed to get a preservice approval.
Deadline
Submit a retrospective authorization request within 90 days after the service is rendered.
Process
Retrospective authorization requests are submitted through GuidingCare (login required). Out-of-network Providers may fax it in using the appropriate prior authorization form.
After submission
We'll review your request and make the determination.
Post-claim
Post-claim for elective inpatient
Post-claim for elective inpatient
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.