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

Claim Disputes

A dispute is the first formal review of the processing of a claim by HAP CareSource MI Health Link (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. HAP CareSource MI Health Link pays 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 Claim Disputes

Claim Appeals

Claim Appeals

A claim appeal is a written request by a provider to review the denial or payment of a claim due to processing errors. For out-of-network providers, please refer to the Non-Participating Providers Appeals and Disputes. 

View Claim Appeals

Clinical Appeals

Clinical Appeals

A clinical appeal is a written request by a provider to review a prior authorization denial with a clinical decision regarding medical necessity. Clinical denials are issued from the HAP CareSource MI Health Link Utilization Management department. You may submit clinical appeals pre- or post-service. All pre-service appeals are clinical appeals, and if not submitted by a physician or physician’s representative, require an Authorization of Representative form for opt-in members and member written consent for opt-out members.

View Clinical Appeals

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.

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:

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 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 60 days from the date of the authorization denial to submit a pre-service appeal. The pre-service appeal must be accompanied with an Authorization of Representative form or a member’s written consent, must be specific to the service requested, is only valid for that appeal and must be signed/dated by the member.
  • Post-Service Appeal: denial of an authorization for a service that has already been completed. You have 60 days from date of service, discharge or authorization denial to submit a post-service appeal. Member consent is not required for post service requests.

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.

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

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 Health Link 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. HAP CareSource MI Health Link 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 Health Link 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 HAP CareSource MI Health Link appeal process.

Extending an Appeal

Members may verbally request that HAP CareSource MI Health Link extend the time frame to resolve any medically necessity appeal request up to 14 days. CareSource may also request an extension.

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).