Know the inpatient admission appeals process for Medicare Plus Blue Utilization Management department

All Michigan health care providers have the right to appeal an adverse medical decision made by Blue Cross Blue Shield of Michigan’s Medicare Plus Blue^SM Utilization Management department.

How to request an expedited appeal

You may request an expedited appeal when a decision needs to be made quickly because a delay may seriously jeopardize the life or health of the member. We won’t consider retrospective requests for expedited status. This decision is final; no other appeal option is available.

Request an expedited appeal by calling 1-866-807-4811. Medicare Plus Blue will notify you of our decision within 72 hours.

How to submit first- and second-level appeal requests

You may submit appeal requests by fax, email or mail:

• Fax: 1-877-495-3755
• Email: MedicarePlusBlueInpatientAppeals@bcbsm.com
• Mail:
  Medicare Plus Blue Inpatient Provider Appeal — Mail Code 1516
  Blue Cross Blue Shield of Michigan
  600 E. Lafayette Blvd.
  Detroit, MI 48226-2927

Time frames
A first-level appeal must be submitted within 45 days of the date of the denial decision. Include additional clarifying clinical information to support the request.

Medicare Plus Blue will notify the provider of our decision within 30 calendar days of receiving all necessary information.

A second-level appeal must be submitted within 21 days from the date of the first-level appeal decision. It must contain at least one of the following:

• New or clarifying information
• A clear statement of what the provider is requesting

If neither is included, Medicare Plus Blue isn’t obligated to review the second-level appeal request. We’ll notify the provider of the decision within 45 calendar days of receiving all necessary information. The plan’s second-level appeal decision is final.

Appeals outside the stated time frames
If you request appeals outside the time frames stated above, we’ll deny the first level of appeal request with a decision of untimely filing. We’ll then process the appeal request as a second level. The decision will be final.

At any step in the appeal process, a plan medical director may obtain the opinion of a same-specialty, board-certified physician or external review board.

Note: If an appeal request is received by Blue Cross outside the designated time frame, we’re not obligated to review the case.