Medicare acute inpatient authorization reviews & appeals

In-network providers:

Retrospective authorizations

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 60 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.

How to make a retrospective request

Situation

Payer not identified at time of service.

Deadline

Submit your retrospective authorization request within 90 days of the date of service. (If 90 days have passed, you must submit a claim and then follow 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

Authorization denied for acute inpatient level of care

Deadline

Submit your Level I authorization appeal within 60 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*.
   
   *If a claim has been filed, 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 authorization appeal as outlined below.

Level II authorization appeal

Deadline

Submit your Level II authorization appeal within 30 days of a Level I appeal denial.

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 choose 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

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.

How to make a retrospective request

Situation

Payer not identified at time of service.

Deadline

Submit your retrospective authorization request within 90 days of the date of service.

Process

Submit an Emergent Inpatient Authorization Request form by fax to 616.975.8858.

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.