Provider Disputes or Appeals

Definitions

HAP CareSource™ MI Health Link (Medicare-Medicaid Plan) provides several opportunities for you to request review of claim or authorization denials. Actions available after a denial include:

Claim 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 Navigate 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 Health Link 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.

HAP CareSource MI Health Link 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, HAP CareSource MI Health Link 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 Navigate 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 Health Link denying coverage, a provider, with the member’s written consent, or member can submit a pre-service or post-service clinical appeal. ­Clinical appeals are reviewed by nurses and physicians not involved in any prior review or subordinate to anyone involved in a prior review. They are also reviewed by practitioners with expertise and knowledge appropriate for treating the member’s clinical condition or disease for the item, service, or drug being requested.

• Pre-Service Appeal: denial of an authorization for a service prior to being completed. A member, a provider or authorized representative acting on behalf of the member, and with the member’s written consent may appeal the decision to deny, terminate, suspend, or reduce services. This is considered a member appeal and will be resolved as expeditiously as the member’s health requires, but always within 30 days plus any extension, if applicable, for a standard appeal. Appeals should be submitted within 60 days from the date of the receipt of the denial, which is presumed to be five days from the date on the notice. Appeals received late will be reviewed for Good Cause. See ‘Extending an Appeal’ for more information on extensions. Part B drug standard appeals will be resolved within seven days may not be extended. The pre-service appeal must be accompanied by a valid Authorization of Representative (AOR) form or equivalent, or written consent which must be specific to the service being appealed, only valid for that appeal, and signed by the member, if applicable. The AOR form is available online. Please see ‘Expediting Clinical Appeals’ for more information on expedited clinical appeals.
  • Pre-service appeals for Medicare or Overlap (Medicare and Medicaid) Services that are not approved by HAP CareSource MI Health Link are forwarded to the Independent External Reviewer (IRE) for Level 2 appeal, or in the event that HAP CareSource MI Health Link does not make a timely decision. Members also have additional rights for State Hearing or External Review for Overlap or Medicaid Services not approved by the plan on appeal, or if the plan does not make a timely decision. Michigan Medicaid Fair Hearing (State Hearing) must be requested within 120 days of the mailing date of the notice of appeal decision. External Review must be requested from DIFS within 127 days of receipt of the notice of appeal decision. Members should exhaust their internal appeal before filing a state hearing or external review request.

• Post-Service Appeal: denials of a service already completed and may include a review for medical necessity. Members or an authorized representative acting on behalf of the member, have 60 days from the date of the receipt of the denial to file an appeal, which is presumed to be five days from the date on the notice. The AOR form is available online.
  • Member appeals will be resolved within 30 days. HAP CareSource MI Health Link will review documentation for Good Cause for late filing of an appeal. Providers requesting review of post-service payment denials should refer to ‘Provider Appeals and Disputes” and “Claim Appeals” for more information. Non-participating provider claim appeals and member appeals for Medicare and Overlap services that are not by HAP CareSource MI Health Link are forwarded to the IRE by HAP CareSource MI Health Link for Level 2 appeal, or in the event that HAP CareSource MI Health Link doesn’t make a timely decision.
  • Members have additional rights for State Hearing or External Review for Overlap or Medicaid services not approved by the plan on appeal, or if the plan does not make a timely decision. State hearing must be requested within 120 days of the mailing date of the notice of appeal decision. External Review must be requested from the Department of Insurance and Financial Services (DIFS) within 127 days of receipt of the notice of appeal decision.

If you have not received an authorization denial from the HAP CareSource MI Health Link 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.

Expediting Clinical Appeals

If the member or provider feel that the standard appeal time frame of 30 days could seriously jeopardize life, health, or member’s ability to regain maximum function, they may ask us to expedite a clinical appeal. HAP CareSource MI Health Link doesn’t take any punitive action against providers for requesting or supporting an expedited request.

A member, a provider or authorized representative acting on behalf of the member, and with the member’s written consent, have 60 days from the date of the receipt of the authorization denial, which is presumed to be five days from the date on the notice, to submit an expedited appeal.

Documentation for Good Cause for late filing of an appeal will be reviewed. The pre-service appeal must be accompanied by a valid AOR form or equivalent, or written consent which must be specific to the service being appealed, only valid for that appeal, and signed by the member, if applicable.

HAP CareSource MI Health Link will review the expedited request as expeditiously as the member’s medical condition requires, and the appeal will be resolved with verbal notification reasonably attempted within 72 hours of receipt of the appeal by the Grievance and Appeal department, unless the time frame is extended, or the appeal request does not meet expedited review criteria. If the appeal is approved, we will authorize or provide the service in this time frame and include with the notification information about the duration or limitations with approval.

HAP CareSource MI Health Link will send an appeal decision letter to the member and AOR, if applicable, as well as a copy to the provider within the 72-hour time frame.

Expedited pre-service appeals for Medicare or Overlap (Medicare and Medicaid) services that are not approved by HAP CareSource MI Health Link are forwarded to the IRE for Level 2 appeal, or in the event that HAP CareSource MI Health Link doesn’t make a timely decision. Members also have additional rights for State Hearing or External Review for Overlap or Medicaid services not approved by the plan on appeal, or if the plan does not make a timely decision. The State Hearing must be requested within 120 days of the mailing date of the notice of appeal decision. External Review must be requested from DIFS within 127 days of receipt of the notice of appeal decision. Members should exhaust their internal appeal before filing a state hearing or external review request.

Please note – there is a limited amount of time to submit additional information for expedited clinical appeals. HAP CareSource MI Health Link will outreach and work with the provider to obtain any needed information for the expedited appeal.

Call us at 1-833-230-2159 to request an expedited clinical appeal.

Denied Expedited Appeals

If HAP CareSource MI Health Link decides not to expedite the clinical appeal because the criteria for expedited review is not met, we will transfer the request to a standard appeal time frame beginning the day the expedited request was received. The member will be given prompt oral notice of the decision to not expedite including the member’s expedited grievance rights related to the decision not to expedite the request. A letter will also be sent to the member at the time of the decision, but not later than two calendar days of the denial to expedite the request, notifying of the decision to not expedite the appeal, the appeal is being transferred the standard appeal time frame of 30 days, and will include the member’s expedited grievance rights and time frames, and the right to request an expedited appeal with provider support of serious jeopardy to life, health or function. 

Extending an Appeal

Members may request that HAP CareSource MI Health Link extend the time frame to resolve any medical necessity appeal request by up to 14 days. We may also request an extension of up to 14 days, if the extension is in the member’s best interest. HAP CareSource MI Health Link will attempt to give the member prompt oral notice of the delay and will notify the member in writing within two calendar days of the reason for the extension and inform the member of the right to file a grievance if the member disagrees with the decision to extend the time frame.

HAP CareSource MI Health Link will issue its determination, and authorize or approve the service if the appeal is approved, as expeditiously as the member’s health condition requires, but no later than upon the expiration date of the extension. Part B drug appeals may not be extended.

Rapid Dispute Resolution and Binding Arbitration

Non-contracted hospital providers who have signed the Hospital Access Agreement and who do not agree with the decision of a disputed claim, or group of claims and have exhausted all efforts to reconcile accounts with HAP CareSource MI Health Link may request a Rapid Dispute Resolution Process within 60 days of the claim appeal decision. You may submit your request to Michigan Department of Health and Human Services (MDHHS).

How to Submit Appeals

You can submit appeals through our HAP CareSource Provider Portal. The HAP CareSource Provider Portal is the most efficient method of submitting appeals.

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.

Updates & Announcements

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

Contact Us

For any questions regarding HAP CareSource MI Health Link’s processes, please contact Provider Services at 1-833-230-2159, Monday through Friday, 8 a.m. to 6 p.m. Eastern Time (ET).