Provider Disputes or Appeals

Definitions

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

Claim Appeals

Claim Appeals

A clinical appeal is a written request by a provider, with the member’s written consent, to review a prior authorization denial with a clinical decision regarding medical necessity. Clinical denials are issued from the HAP CareSource MI Coordinated Health Utilization Management department. You may submit clinical appeals pre- or post-service.

View Claim Appeals

Provider Disputes

Provider Disputes

A dispute is the first formal review of the processing of a claim by HAP CareSource™ MI Coordinated Health (HMO D-SNP) (excluding denials based on medical necessity) and is typically submitted by participating providers prior to claim appeal. You can submit a claim payment dispute when you disagree with payment and any other post-service claim denial. We pay non-contracted providers, as Medicare would have paid for the same service. If your disagreement is limited to the amounts a non-contracted provider could collect if the beneficiary were enrolled in original Medicare pursuant to § 422.214(a)(l), you should use the plan’s internal payment dispute process to:

HAP CareSource
Attn: Grievance & Appeals
P.O. Box 1025
Dayton, OH 45401

View Provider Disputes

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:

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.

Updates & Announcements

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