Non-Medicare outpatient, home health & DME authorization appeals

Use the instructions in the sections below to submit appeals for outpatient, home health and durable medical equipment (DME) medical authorizations for commercial, individual/ACA and Medicaid members. Click on the headings below to expand each section.

Note: If you have a denied outpatient, home health or DME 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.

Pre-service

Level I medical authorization appeal

Situation

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

Deadline

Appeal the medical authorization denial within 65 days from notice of initial determination.

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 and enter in the required fields. Upload clinical documentation to support your appeal.
  5. 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 medical authorization appeal

Deadline

Within 30 days of adverse Level I appeal decision

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 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, 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

Retrospective authorization requests

Situation

You rendered a service that required prior authorization but failed to get preservice approval.

Deadline

You have 90 days after the service is rendered to submit a retrospective request. If more than 90 days have passed since the service was rendered, you must submit a claim and file follow the post-claim appeal process. 

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. If you’re not satisfied with the outcome, you may submit a claim and 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 outpatient, home health or DME 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.