Non-Medicare behavioral health authorization reviews and appeals

Level I behavioral health authorization appeal

Situation

You received a denial on your prior authorization request and haven't submitted a claim after the service was rendered.

Deadline

Submit your behavioral health authorization appeal within 60 days of the initial prior authorization denial.

Process

In-network providers

1. Log into your prism account.
2. Click the Appeals tab.
3. Click New Pre-Claim Appeal.
4. Choose the most appropriate request type:
   
   Appeal, pre-claim inpatient emergent: use when an emergent mental health inpatient authorization has been denied and no claim has been submitted.
   
   Appeal, pre-claim inpatient elective: use when inpatient authorizations have been denied preservice and no claim has been submitted. **DO NOT submit emergent inpatient mental health admissions here. Use for Detox; SUD Residential; Inpatient ECT and Mental Health Residential.
   
   Appeal, pre-claim outpatient: use when outpatient behavioral health authorizations that have been denied preservice and no claim has been submitted. Use for TMS; ABA; IOP and Partial Hospitalization.
   
   
5. Complete the required fields, uploading supporting documentation.
6. Click Submit.

Out-of-network providers

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:

• Provider appeal letter
• Supporting clinical documentation including Level I Appeal form; admission summary, physician, documentation, medical testing, and a discharge summary, as applicable
• Priority Health denial letter (recommended)

After submission

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).

Level II behavioral health authorization appeal

Situation

You received a denial on your level I appeal.

Deadline

Within 30 days of an adverse level I appeal decision.

Process

In-network providers

1. Log into your prism account.
2. Click the Appeals tab.
3. Click New Pre-Claim Appeal.
4. Choose the most appropriate request type:
   
   Appeal, pre-claim inpatient emergent: use when an emergent mental health inpatient authorization has been denied and no claim has been submitted.
   
   Appeal, pre-claim inpatient elective: use when inpatient authorizations have been denied preservice and no claim has been submitted. **DO NOT submit emergent inpatient mental health admissions here. Use for Detox; SUD Residential; Inpatient ECT and Mental Health Residential.
   
   Appeal, pre-claim outpatient: use when outpatient behavioral health authorizations that have been denied preservice and no claim has been submitted. Use for TMS; ABA; IOP and Partial Hospitalization.
   
   
5. Complete the required fields, uploading supporting documentation.
6. Click Submit.

Out-of-network providers

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:

• Provider appeal letter, outlining what you're appealing and why we should reconsider our decision
• New pertinent supporting documentation to support your appeal

After submission

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).

Medicaid plan rules

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.

Retrospective authorization requests

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.

• Level I behavioral health authorization appeal: Request within 60 days of initial decision
• Level II behavioral health 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.

How to make retrospective authorization request

Situation

Payer not identified at time of service.

Deadline

Within 90 days after the service is rendered.

Process

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.

After submission

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.

Level I behavioral health authorization appeal

Situation

Authorization denied for inpatient level of care

Deadline

Within 60 days of the initial authorization denial

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. 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.

Level II behavioral health authorization appeal

Deadline

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*.
   
   *Note: If you've submitted a claim, 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.