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Prior Authorization (Part C)

What is Prior Authorization?

Prior Authorization is a process which must be completed before you get some services. Some services must get prior authorization, also called Prior Approval, before the plan will pay for it. Your doctor will make the request, you can make the request too. We will need medical records and notes from your doctor. Other information that shows why you need the item or service will be needed. Call your doctor if you need this information.

Which services require Prior Authorization?

To get a list of services that require prior authorization, please call Michigan Complete Health (MMP) at 1-844-239-7387 (TTY: 711). 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. The call is free.

For out of network services you must get prior authorization. You do not need prior authorization for emergency care, out-of area urgent care, or out-of area dialysis.

What is the process for getting Prior Authorization?

You, or your appointed representative may also file for an authorization/service request (organization determination) by  contacting Michigan Complete Health (MMP). Please see contact information below.

  • Phone: 877-372-6121
  • Fax: 866-596-1054 Outpatient
  • Fax: 866-596-1046 Inpatient
  • Address:

Concerto/Michigan Complete Health
85 Enterprise, Suite 200
Aliso Viejo, California 92656

Providers need to send  prior authorizations through the webportal, phone or fax as listed above.

If you need a quick response due to your health, ask for a fast coverage decision.  You will be told if we approve the service within 72 hours after we get your request. You will be told no later than 14 calendar days for all other requests.

If we find that your health may be in danger we will hurry your request.

We will tell you what we decide in writing or by telephone. In the case of an emergency, you do not need prior authorization.

Prior authorization is not a guarantee of payment. The plan has the right to review the service for medical need after you receive the services. The member must be eligible for services. Some services have limits. Some benefits have exclusions.

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.

 

Last Updated: 02/23/2018
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