Non-Medicare outpatient, home health & DME authorization reviews & appeals

Use the instructions in the sections below to submit reviews and appeals requests 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 medical authorization on file, submit a medical authorization appeal – not a post-claim review request.

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 60 days from notice of initial determination.

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 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 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. 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

You have 90 days after the service is rendered to submit a retrospective request. If your request is denied, you may submit a claim and follow the post-claim appeal process.

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.

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. 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 and you’ve submitted a claim, which denied due to lack of prior authorization.

Deadline

File post-claim appeals within 180 calendar days from the claim denial.

Process

Follow the post-claim appeal process.