Grievances and appeals

If a non-contracted provider disagrees with a payment on a submitted claim for an item or service that’s covered by Medicare only or by both Medicare and Medicaid, the non-participating provider has the right to request a non-contracting provider payment dispute. You must submit the dispute in writing, with supporting documentation stating that you should receive a different payment under original Medicare, within 60 calendar days of the remittance advice.

If you still disagree with the decision, you can submit a request in writing for an Independent Review Entity (IRE) review within 180 calendar days of the remittance advice. The decision letter will provide information on how to request an IRE review. The IRE will process the request within 60 calendar days of receipt and will notify you of their decision concerning the appeal. If the decision is overturned, we’ll put the decision into effect within 30 calendar days of receipt of IRE’s notification of decision.

Non-PAR Claim Appeal form (PDF
 

1. Contact Member Services by phone or in writing
 

Call Member Services at 1-855-676-5772 (TTY: 711). You can get help 24 hours a day, 7 days a week. They’ll let you know if there is anything else you need to do.

If you don’t wish to call (or you called and were not satisfied), you can put your grievance in writing and send it to us. If you do this, it means that we will use our formal procedure for answering grievances.

Whether you call or write to submit a grievance on behalf of a member, you will need to complete and submit a completed Appointment of Representative (AOR) form designating you as the representative. Both you and the member must sign the AOR form. You can learn more about appointing a representative.
 

2. Await our decision as we process your grievance
 

During this period, we will:
 

• Acknowledge your grievance
• Respond to your complaint within 30 calendar days, if we can’t resolve your grievance over the phone
• Respond to you in writing within 30 calendar days if you made your grievance in writing or asked for a written response

A member may make a grievance to us regarding concerns of the quality of care they received. Members can also make grievances about quality of care to the Quality Improvement Organization (QIO).

For items or services covered by Medicare, an enrollee or their authorized representative may make a quality-of-care concern with the Centers for Medicare & Medicaid Services (CMS) contracted QIO. The QIO for Michigan is Livanta.

Livanta contact information:

Address:

Livanta
10820 Guilford Rd., Suite 202
Annapolis Junction, MD 20701

Phone: 1-888-524-9900
Fax: 1-888-985-8775

Both in-network and out-of-network providers may file an appeal when we untimely deny a request for coverage or do not issue a decision on a request for coverage in a timely manner.

Upon denial of coverage in whole or in part for an item or service that is covered by Medicaid only, you’ll also have the option to request an appeal through the State agency after completion of the plan appeal process.

If you’re filing an appeal on behalf of the member, or request an expedited appeal, the appeal will be processed as a member appeal and subject to the requirements of the member appeal policy.

The grievances and appeals department assumes primary responsibility for coordinating and managing provider grievances.
 

Some timelines to note:
 

• Within 3 business days: We’ll send you a letter letting you know that we received your appeal.
• Within 45 calendar days: We’ll resolve your appeal and make a decision.
• Within 2 business days of our decision: We’ll let you know our decision via phone, email, fax or mail.

• For items or services covered by Medicaid only: A member or their representative may submit complaints directly to the state, through the Medicaid Beneficiary Help Line. Members can call 1-800-642-3195.
• For items or services covered by Medicare only: A member or their representative may submit complaints directly to CMS. They can call 1-800-MEDICARE (1-800-633-4227).
• For items or services covered by both Medicare and Medicaid: A member or their representative may submit complaints directly to the State, through the Medicaid Beneficiary Help Line. Members can call 1-800-642-3195. Or they can contact CMS at 1-800-MEDICARE (1-800-633-4227).

A member may designate someone they know (a friend, relative, lawyer or provider) to act on their behalf on a grievance. This person is known as their representative. Members should complete an Appointment of Representative (AOR) form to designate a representative to act on their behalf.
 

Members can also call Member Services and ask that an AOR form be mailed to them. The form must be signed by the member and by the person they designate to act on their behalf.
 

If the representative is the prescribing or other treating provider or holds durable power of attorney or guardianship papers, an Appointment of Representative form is not required.

What is a coverage decision?
 

A coverage decision is the initial decision we make about a member’s benefits and coverage. It also determines the amount we will pay for the member’s medical services or drugs. We make a coverage decision whenever we decide what is covered for an enrollee and how much we’ll pay. If you’re not sure if a service is covered by Medicaid, you or the member can ask for a coverage decision before the service is provided.

Who can I call with questions about coverage decisions?
 

• Member Services: To request a coverage decision or an appeal on a member’s behalf, you can call Member Services at 1-866-316-3784 (TTY: 711). You can get help Monday through Friday, 8 AM to 5 PM. You can also ask for a coverage decision or appeal in writing.
• The Beneficiary Help Line: This help line helps solve problems for Medicaid enrollees. Just call 1-800-642-3195. 

Member representative
 

Members can also ask another provider, friend or family member to act on their behalf. This person will act as the member's representative to ask for a coverage decision or make an appeal.