Provider Disputes or Appeals

We provide several opportunities for you to request review of claim or authorization denials. Actions available after a denial include:

Provider Disputes

If you believe a claim was processed incorrectly due to incomplete, incorrect or unclear information on the claims, you should submit a corrected claim. You should not file a dispute or appeal. A Correct Claim should be submitted. Refer to the Claims page or the Provider Manual for further information related to claims submission.

Please note: All non-participating providers should submit their claim issues as Claim Appeals and not as a Payment Dispute.

Claim Dispute Process

Requests for adjustment for underpayment or overpayment may be submitted through the claim payment dispute process. You should not submit an appeal for this type of review.

A request for review of a claim denial should be submitted as an appeal if the denial was for lack of authorization or insufficient authorization.

Claim disputes must be submitted in writing.

The dispute must be submitted within 60 calendar days of the date of payment or the date of the original claim rejection. 

At a minimum, the dispute must include:

• Sufficient information to identify the claims in dispute.
• A statement of why you believe a claim adjustment is needed.
• Pertinent document to support the adjustment.

Incomplete requests will be returned with no action taken. The request must be resubmitted with all necessary information within 60 calendar days of the claim payment or 10 calendar days of the date on the letter notifying you of the incomplete request.

Claim disputes can be submitted to HAP CareSource MI Coordinated Health through the following methods:

• Online: HAP CareSource Provider Portal
• Mail:
  HAP CareSource
  Attn: Grievance & Appeals
  P.O. Box 1025
  Dayton, OH 45401

Mail submissions are only excepted if the attachment is greater than 100 MB and not able to be submitted through the portal.

We will render a claim dispute decision letter within 30 calendar days of receipt. If the decision is to uphold the original claim adjudication, you may appeal the claim adjudication if timely filing rights still apply.

Claim Appeals

If you do not agree with a denial on a processed claim, you have 60 calendar days from the date of service or discharge, unless otherwise specified in your contract, to submit an appeal.

If you do not submit an appeal in the required time frame, we will not reconsider the claim, and the appeal will be dismissed. You will receive notification in writing of the appeal decision. If your appeal is approved, your payment will appear on the Explanation of Payment (EOP).

Please note: If you believe a claim processed incorrectly due to incomplete, incorrect or unclear information, you should submit a corrected claim through the claim submission process. You do not need to file an appeal. You have 365 days from the date of service or discharge to submit a corrected claim. Refer to the Claims page or the Provider Manual for further information related to claims submission.

Clinical Appeals

If you disagree with a clinical decision we have made regarding medical necessity, we make it easy for you to be heard.

After receiving a letter from HAP CareSource MI Coordinated Health denying coverage, a provider or member can submit a pre-service or post-service clinical appeal.

• • Pre-Service Appeal: denial of an authorization for a service prior to being completed. You have up to 60 calendar days from the date of receipt of the initial denial letter, with date of receipt presumed to be 5 calendar days from the date on the initial denial letter, to file an appeal with member written consent. Please use the authorization of representative form (coming soon).

• Post-Service Appeal: denial of an authorization for a service that has already been completed. You have up to 60 calendar days from the date of receipt of the initial denial letter, with date of receipt presumed to be 5 calendar days from the date on the initial denial letter, to file an appeal with member written consent. Please use the authorization of representative form (coming soon).

If you have not received an authorization denial from the HAP CareSource MI Coordinated Health Utilization Management department for a service that requires a prior authorization this is considered a claim appeal and should not be submitted as a retro-authorization.

How to Submit Appeals

The most efficient way to submit appeals is through our  HAP CareSource MI Coordinated Health Provider Portal.

Include the following required documentation:

• Progress notes including symptoms and their duration, physical exam findings, conservative treatment that the member has completed, preliminary procedures already completed and the reason service is being requested
• Any documentation of specialists’ reports or evaluations, any pertinent previous diagnostic reports and therapy notes
• If the service has already been provided, a copy of the original remittance advice and/or the denied claim
• If filing an appeal on behalf of a member or for pre-service issues, the member’s written consent, which must be specific to the service being appealed, is only valid for that appeal and must be signed by the member
• Non-contracted providers: If the service has already been provided, a completed and signed Waiver of Liability (WOL) Form (coming soon).

Expediting Clinical Appeals

If you feel that your patient’s life or health is at risk if a decision about care is not made in a timely manner, you may ask us to expedite a clinical appeal. Call us at 1-833-230-2159 to request an expedited clinical appeal.

Notification of Resolution

HAP CareSource MI Coordinated Health will decide whether to expedite an appeal within 24 hours. We will make reasonable efforts to provide prompt verbal notification to the member of the decision to expedite or not expedite the appeal; the attempt will be made by phone. If the member is in a facility, the provider or facility will be notified on the same business day of the decision.

Expedited appeals will be resolved and verbal notification will be made within 72 hours of receipt of the appeal or as expeditiously as the medical condition requires unless the resolution time frame is extended. We will send written notification to both the provider and the member on the same business day of the decision.

Denied Expedited Appeals

If HAP CareSource MI Coordinated Health decides not to expedite the clinical appeal, we will send written notification within two calendar days of receipt of the appeal to both the member and the provider. This notification will include the determination to process the appeal as a standard appeal and any additional appeal rights the member may have related to our decision. The appeal will be resolved within 30 calendar days from the date the appeal was received and follow the standard appeal process.

Extending an Appeal

Members may verbally request that HAP CareSource MI Coordinated Health extend the time frame to resolve any medically necessity appeal request up to 14 days. HAP CareSource may also request an extension of up to 14 days if the extension is in the member’s best interest.

Updates & Announcements

Please refer to our Updates & Announcements page for notifications of changes that may impact your appeal.