Non-Medicare post-acute authorization reviews & appeals

Use the instructions in the sections below to submit reviews and appeals requests for post-acute medical authorizations for commercial, individual/ACA and Medicaid members. Click on the headings 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

Situation

You received a denial from the initial prior authorization review. 

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.

Post-service / pre-claim or post-claim with denied auth

Retrospective authorization request

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 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 filing a post-claim level I appeal.

Situation

Member went to post-acute facility and thought to be covered under different insurance or no prior authorization obtained for extenuating circumstances.

Deadline

Submit a retrospective authorization request within 90 days after the service is rendered. After 90 days, you must file a claim and submit a post-claim level I appeal.

Process

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

After submission

We will make a determination within 30 days 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 60 days of the initial 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. 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.