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August 2018
Appealing Medicare Plus Blue PPO acute inpatient authorization decisions
Our plan medical directors make denials of care for Medicare Plus BlueSM PPO acute inpatient authorizations related to medical necessity or medical appropriateness based on:
- Review of pertinent medical information
- Consideration of the member’s benefit coverage
- Information from the attending physician and primary care physician
- Clinical judgment of the medical director
All providers have the right to appeal an adverse decision made by the Medicare Plus Blue PPO Utilization Management staff. The two-step appeal process for the provider is designed to be objective, thorough, fair and timely.
At any step in the appeal process, a plan medical director may obtain the opinion of a same-specialty, board-certified physician or an external review board.
When we receive a provider appeal request and a member appeal is in-process, the member appeal takes precedence. When the member appeal process is complete, its decision is final and we won’t process the provider appeal.
Guidelines for provider appeal requests
(for medical necessity or medical appropriateness determinations) |
Expedited appeals |
A practitioner may request expedited appeals when circumstances need a decision in a short period of time, because a delay may seriously jeopardize the life or health of the member.
We won’t consider retrospective appeals (for service already provided to the member) for an expedited appeal.
You may verbally request decisions about precertification of urgent care and concurrent cases that result in denial.
Medicare Plus Blue notifies the provider of the decision within 72 hours of receiving the request.
Start an expedited appeal by calling a plan medical director or designee at 1-866-807-4811.
This decision is final and no other appeal choice is available to the provider. |
Level One appeals |
Are due to Medicare Plus Blue within 45 calendar days of the date noted on the written denial notification.
Requests must include additional clarifying clinical information to support the request.
Medicare Plus Blue notifies the provider of the decision within 30 calendar days of receiving all necessary information.
Submit requests via any of the following methods.
Fax:
1-877-495-3755
Email:
MedicarePlusBlueInpatientAppeals@bcbsm.com
Mail:
Medicare Plus Blue Inpatient Provider Appeal
Blue Cross Blue Shield of Michigan
Mail Code 1516
600 E. Lafayette Blvd.
Detroit, MI 48226-2998 |
Level Two appeals |
Are due to Medicare Plus Blue within 21 calendar days of the date noted on the level-one appeal decision notification.
Level-two appeal requests must include at least one of the following:
- New or clarifying clinical information
- A clear statement that the provider is requesting a Medicare Plus Blue physician reviewer who’s different from the one who reviewed the level-one appeal
If neither the clinical information nor the request for a different physician reviewer is provided, Medicare Plus Blue isn’t bound to review the level-two appeal request.
Send level-two requests to the same fax number, email or mailing address as level-one appeal requests.
Medicare Plus Blue notifies the provider of the decision within 45 calendar days of receiving all the necessary information. This decision is final. |
Time frames
Medicare Plus Blue isn’t obligated to review cases when it receives an appeal request outside of the allowed time frame. We’ll send a letter to the requesting provider — either advising that we didn’t review the appeal or notifying the physician of the outcome of the request (if the plan decides to review the case).
Preservice appeals
You can request a preservice adverse decision appeal only when a service hasn’t yet been rendered (the member isn’t yet admitted to inpatient status).
To request a preservice appeal, call Provider Service at 1-866-309-1719. If you’re unsatisfied with the decision, then submit an appeal in writing within 60 days of the initial decision to:
Medicare Advantage PRS- Appeals
Attn: First Level Appeal
Blue Cross Blue Shield of Michigan
P.O. Box 33842
Detroit, MI 48232-5842
For more information, see the provider manual. | 
