Part C Appeals

Important Information About Your Appeal Rights

There are two kinds of appeals:

Internal Appeal – If you don’t agree with a decision we make about services or payment, you have the right to appeal.  An Internal Appeal (also called a Level 1 Appeal) is the first appeal to our plan.  We will review our decision and let you know what we have decided. We’ll give you a written decision on a standard appeal 30 days after we get your appeal. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more days. If we decide to take extra days to make the decision, we will send you a letter that explains why we need more time. You must ask for an Internal Appeal within 60 days from the date on the letter we sent to tell you our decision.

Fast Appeal – We’ll give you a decision on a fast appeal within 72 hours after we get your appeal.

We’ll give you a fast appeal if a doctor asks for one for you or supports your request.  If you ask for a fast appeal without support from a doctor, we’ll decide if your request requires a fast appeal.  If we don’t give you a fast appeal, we’ll give you a decision within 30 days.

How to ask for an appeal with Michigan Complete Health (MMP).

Step 1: You, your authorized representative, or your doctor must ask us for an appeal.  Your written request must include:

  • Your name
  • Address
  • Member number
  • Reasons for appealing
  • Any proof you want us to review, such as medical records, doctor’s letter, or other information that explains why you need the item or service. Call your doctor if you need this information.

You can ask to see the medical records and other documents we used to make our decision before or during the appeal. At no cost to you, you can also ask for a copy of the rules we used to make our decision.

Step 2: Mail, fax, deliver your appeal or call us.

For an Internal Appeal:

Michigan Complete Health (MMP)
ATTN: Appeals and Grievances
7700 Forsyth Blvd.
St. Louis, MO 63105
Phone: 1-844-239-7387 (TTY: 711)
Fax: 1-844-273-2671

Hours are from 8 a.m. to 8 p.m., seven days a week.  TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

If you ask for a standard appeal by phone, we will send you a letter confirming what you told us.

For a Fast Appeal:               

Phone: 1-844-239-7387 (TTY: 711)
Fax: 1-844-273-2671

Hours are from 8 a.m. to 8 p.m., seven days a week.  TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

What happens next?  

If you ask for an appeal and we choose to deny your request for a service or payment of a service, we’ll send you a written decision and send your case to an independent reviewer. If the independent reviewer denies your request, the written decision will explain if you have additional appeal rights.

There are two ways to make an External Appeal for Michigan Medicaid services and items: 1) Fair Hearing and/or 2) External Review.

You have the right to request a Fair Hearing from the Michigan Administrative Hearings System (MAHS). A Fair Hearing is an impartial review of a decision made by Michigan Complete Health (MMP). You may request a Fair Hearing before, during, after, or instead of the Internal Appeal withMichigan Complete Health (MMP).

You must ask for a Fair Hearing within 90 days from the date on the letter that told you that a Michigan Medicaid covered service was denied, reduced, or stopped. If you are asking for Fair Hearing because the plan decided to reduce or stop a service you were already getting, you must file your appeal within 12 days from the date of the adverse action notice or prior to the date of action if you want your benefits for that service to keep going while the appeal is pending.

To ask for a Fair Hearing from MAHS, you must complete a Request for Hearing form. We will send you a Request for Hearing form with the coverage decision letter. You can also get the form by calling the Medicaid Beneficiary Help Line at 1-800-642-3195 (TTY: 1-866-501-5656), open Monday through Friday from 8:00 AM to 7:00 PM. Complete the form send it to:

Michigan Administrative Hearing System
Department of Community Health
PO Box 30763
Lansing, MI 48909

FAX: 517-373-4147

You can also ask for an expedited (fast) Fair Hearing by writing to the address or faxing to the number listed above.

After your Fair Hearing request is received by MAHS, you will get a letter telling you the date, time, and place of your hearing. Hearings are usually done over the phone, but you can request that your hearing be done in person.

MAHS must give you an answer in writing within 90 days of when it gets your request for a Fair Hearing. If you qualify for an expedited Fair Hearing, MAHS must give you an answer within 72 hours. However, if MAHS needs to gather more information that may help you, it can take up to 14 more days.

Following receipt of the MAHS final decision, you have 30 days from the date of the decision to file a request for rehearing/reconsideration and/or to file an appeal with the Circuit Court.

You also have the right to request an External Review through the Michigan Department of Insurance and Financial Services (DIFS). You must go through our Internal Appeals process first before you can ask for this type of External Appeal.

Your request for an External Review must be submitted within 60 days of your receipt of our Internal Appeal decision. If you qualified for continuation of benefits during the Internal Appeal and you submit your request for an External Review within 12 days from the date of the Internal Appeal decision, you can choose to get the disputed service during the review.

To ask for an External Review from DIFS, you must complete the Health Care Request for External Review form. We will send you this form with our appeal decision letter. You can also get a copy of the form by calling DIFS at 1-877-999-6442 (TTY: 711). Complete the form and send it with all supporting documentation to:

DIFS – Office of General Counsel
Health Care Appeals Section
PO Box 30220
Lansing, MI 48909-7720

FAX: 517-241-4168

If your request does not involve reviewing medical records, the External Review will be done by the Director of DIFS. If your request involves issues of medical necessity or clinical review criteria, it will be sent to a separate Independent Review Organization (IRO).

If the review is done by the Director and does not require review by an IRO, the Director will issue a decision within 14 days after your request is accepted. If the review is referred to an IRO, the IRO will give its recommendation to DIFS within 14 days after it is assigned the review. The Director will then issue a decision within 7 business days after it gets the IRO’s recommendation.

If the standard time it takes us for review would put your life or health at risk, you may be able to qualify for an expedited (fast) review. An expedited review is completed within 72 hours after your request. To qualify for an expedited review, you must have your doctor verify that the time it takes us for a standard review would put your life or health at risk.

If you disagree with the External Review decision, you have the right to appeal to Circuit Court in the county where you live or the Michigan Court of Claims within 60 days from the date of the decision.

For more information, or contact numbers that enrollees/physicians can use for process or status questions, please call Michigan Complete Health (MMP) at 1-844-239-7387. Hours are from 8 a.m. to 8 p.m., seven days a week.  TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

Last Updated: 09/30/16
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