Michigan acute inpatient facilities should submit peer-to-peer review requests, appeals through the e-referral system

Acute inpatient facilities in Michigan should use the e-referral system to submit peer-to-peer review requests and appeals related to prior authorization requests for inpatient acute care medical and surgical (non-behavioral health) admissions. Submitting these requests through the e-referral system involves completing questionnaires and attaching clinical documentation when applicable.

Submitting through the e-referral system offers a streamlined process that:

• Can help you meet submission deadlines and get faster responses
• Allows you to see initial prior authorization requests, peer-to-peer review requests and appeals in the same location
• Prevents the need to search through emails, wonder if a fax went through or call to confirm that a request was received

Here are some resources you can use to learn more:

• The How to request a peer-to-peer review with a Blue Cross or BCN medical director document. We’ve updated it to include details you’ll need to know about using the e-referral system. In the table under Non-behavioral health services, look for the row labeled Inpatient non-behavioral health non‑elective admissions — in acute care hospitals for medical and surgical admissions.
• The Submitting requests for appeals and peer-to-peer reviews in e‑referral training course. For instructions on accessing this course, refer to this article in the March 2024 issue of The Record.
• The e-referral User Guide. Look in the section titled "Submit an inpatient authorization."

When the e-referral system is not available, you can:

• Submit peer-to-peer requests using the Physician peer-to-peer request form (for non-behavioral health cases). Follow the instructions on the form.
• Submit appeals through traditional methods (fax, email or U.S. mail) as instructed in the denial letter.

You can’t use the e-referral system to submit a peer-to-peer review request or appeal for prior authorization requests that:

• Were submitted prior to the member’s admission
• Were administratively denied
• Are for inpatient behavioral health admissions
• Are for outpatient medical, surgical or behavioral health services
• Are for inpatient hospital clinical edit denials, pre-service denials, post-service audit overturns, post-claim bundling and claim denials
• Are for professional service authorization denials
• Are for denials made by a vendor

Non-Michigan facilities can’t use the e-referral system to submit peer-to-peer review or appeal requests. They must continue to:

• Submit peer-to-peer requests using the Physician peer-to-peer request form (for non-behavioral health cases).
• Submit appeals through traditional methods (fax, email or U.S. mail) as instructed in the denial letter.