Non-Medicare post-acute authorization appeals

Situation

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

Process

Pre-service authorization denials use the member appeal process. Members can initiate an appeal online.

Should you need to appeal on behalf of the member, follow this process:

1. Visit the member Filing a complaint webpage.
2. Select the page link that corresponds to the member's plan type: Fully-funded group, self-funded group, MyPriority, Medicaid / Healthy Michigan, FEHB
3. On the page that opens, download the paper appeal form from the. Be sure to have the member sign Section 2: Appointment of a representative.
4. Return the completed form to Priority Health as instructed on the form.

Retrospective authorization request

Situation

The member went into a post-acute facility and was thought to be covered under different insurance, or no prior authorization was obtained for extenuating circumstances.

Deadline

Submit retrospective authorization requests up to 90 days after a service is rendered. If your 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 filing a post-claim level I appeal. 

Process

Retrospective authorization requests are submitted through GuidingCare (login required).

After submission

We'll make a determination within 14 days (Medicaid plans) / 30 days (commercial / ASO plans) of the request. If you’re not satisfied with the outcome, you can file a level I medical authorization appeal.

Level I medical authorization appeal

Situation

Continuing stay denied or stay extended without continuing stay days request.

Deadline

Within 65 days of the 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*.
   *Note: If you have a claim on file, 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. 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 medical authorization appeal.

Level II medical 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*.
   *Note: If you have a claim on file, 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, 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.