Grievances and Appeals

Waiver of Liability (PDF) 08/14/2024

Provider Grievance & Appeals Process for Denied Claims

Contracted providers can request an appeal when acting strictly on their own behalf and the member is not at financial risk, such as for an unapproved inpatient admission. MeridianComplete's appeal process for these cases is independent of Medicare regulations and mirrors the non-Medicare provider appeal process.

MeridianComplete offers a post-service claim appeal process for disputes related to denial of payment for services rendered to MeridianComplete members. This process is available to all providers, regardless of whether they are in or out of network.

What Types of Issues Can Providers Appeal?

The appeals process is in place for two main types of issues:

1. The provider disagrees with a determination made by MeridianComplete, such as request for surgery or admission to a Skilled Nursing Facility.

2. The provider is requesting an exception to a MeridianComplete policy, such as prior authorization requirements. In this case, the provider must give an explanation of the circumstances and why the provider feels an exception is warranted in that specific case.

For Medicare, a treating provider may request a peer-to-peer discussion as part of an informal process to encourage dialogue between the requesting provider and MeridianComplete's physician reviewer. It is preferred that peer-to-peer discussion occur prior to a final decision. However, this process cannot be used to request a reconsideration of the initial adverse decision. Any request to change an initial adverse decision must be handled through the appeals process - not through a peer-to-peer discussion.

If you disagree with an adverse preapproval decision and wish it to be reconsidered, you must request an appeal by contacting MeridianComplete Member Services at 1-855-323-4578.

A provider's lack of knowledge of a member's eligibility or insurance coverage is not a valid basis for an appeal. Providers cannot appeal denials due to member ineligibility on the date of service or non-covered benefits.

How to File a Post-Service Claim Appeal

1. Please send a letter explaining the nature of your appeal and any special circumstances that you would like MeridianComplete to consider.

2. Attach a copy of the claim and documentation to support your position, such as medical records.

3. Send the appeal to the following address:

MeridianComplete - Appeals Coordinator
PO Box 44260
Detroit, MI 48244

Fax: 313-294-5552

Timeframe for Filing a Post Service Appeal

Appeals must be filed within one year from the date of service.

MeridianComplete will allow an additional 120-day grace period from the date of the last claim denial, provided that the claim was submitted within one year of the date of service. Appeals submitted after the time frame has expired will not be reviewed.

Response to Post Service Claims Appeals

MeridianComplete typically responds to a post-service claim appeal within 60 days from the date of receipt. If additional information is needed, such as medical records, then MeridianComplete will respond within 30 days of receiving the necessary information. Providers will receive a letter with MeridianComplete's decision and rationale.

There is only one level of appeal available within MeridianComplete. All appeal determinations are final. If a provider disagrees with MeridianComplete's determination regarding an appeal, the in- or out-of-network provider may pursue the following option:

Binding Arbitration - A provider may initiate arbitration by making a written demand for arbitration to MeridianComplete. The Provider and MeridianComplete agree to mutually select an arbitrator and the process for resolution.

If you have any questions about the post-service claim appeal process, please call MeridianComplete Provider Services at 1-855-323-4578 for more information.

Denials and Appeals

All denial determinations are rendered by physicians. A nurse reviewer contacts the provider telephonically to inform them of the denial decision, reason for the denial and contact information to discuss the denial with our medical director. Written denial notification is sent via fax and mailed to the member. Treating physicians who would like to discuss a utilization review determination with the decision-making medical director may contact the MeridianComplete Utilization Management Department at 1-855-323-4578.

The written denial notification will include the reason for the denial, the reference to the benefit provision and/or clinical guideline on which the denial decision was based, and directions on how to obtain a copy of the reference. You may contact the Utilization Management Department any time at 1-855-323-4578, to request a copy of MeridianComplete's medical necessity guidelines.

Expedited Appeal

An expedited appeal is a request to change a denial decision for urgent care. Urgent care is any request for medical care or treatment with respect to which the application of the time period for making non-urgent care determinations could seriously jeopardize the life or health of the member or the member's ability to regain maximum function, based on a prudent layperson's judgment.

Inpatient services that are denied while a member is in the process of receiving the services are considered an urgent concurrent request and are therefore eligible for an expedited appeal.

Non-Urgent Pre-Service Appeal

Providers, acting on behalf of a member, may request an appeal of denial in advance of the member obtaining care or services.

MeridianComplete will provide acknowledgement of the appeal within three days of receipt of the request. No physician will be involved in an appeal for which he/she made the original Adverse Determination. No physician will render an appeal decision who is a subordinate of the physician making the original decision to deny.

Refer to the Billing and Payment section for directions on Post-Service Appeals.

TURN AROUND TIMES FOR PROCESSING APPEALS

Appeal Type	Makes Decision	Fax/Phone Notification	Written Notification
Expedited Appeal	Completed as expeditiously as the medical condition requires, but no later than 72 hours after the receipt Inpatient admissions are eligible if the member is receiving services at the time of the denial	Within 72 hours of the decision.	Within 72 hours of receipt of the request.
Pre-Service Appeals	Within 30 calendar days of receipt of the appeal.	Within 30 calendar days of receipt of the appeal.	Within 30 calendar days of receipt of the appeal.

We may extend the timeframe by up to 14 calendar days if you request an extension, or if we justify the need for additional information and the extension is in your best interest. If we take an extension, we will call you and send a letter to let you know.

Levels of Appeal/Grievance

The levels of the appeals process are listed below. If an appeal is not resolved at one level, it proceeds or can proceed to the next.

1. MeridianComplete Standard or Fast Appeals Process
2. Review by an Independent Review Entity (IRE)
3. Review by an Administrative Law Judge (ALJ)
4. Review by a Medicare Appeals Council (MAC)
5. Review by the Federal Court

Members can appeal a medical decision within 60 calendar days of receiving our letter denying the initial request for services or payment on their own behalf. They can also designate a representative, including a relative, friend, advocate, doctor or other person, to act for them. The member and the representative must sign and date a statement giving the representative legal permission to act on the member's behalf. This statement must be sent to MeridianComplete at:

MeridianComplete - Appeals Coordinator
PO Box 44260
Detroit, MI 48244

Fax: 313-294-5552

Members should call MeridianComplete at 1-855-323-4578 (TTY 711), Monday - Friday from 8 a.m. - 8 p.m. to learn how to name an authorized representative.

Please include copies of any additional information that may be important to your Appeal, and mail/fax that information to the following address/fax number The timeframe to submit additional information for an expedited appeal is limited due to the short timeframe to process your appeal:

If you ask for an appeal and we continue to deny your request for a service or payment of a Medicare-covered service, we will send you a written decision and forward your case to the Medicare Independent Review Entity (IRE). If the IRE denies your request, the written decision will explain if you have additional appeal rights.

You may also have the right to request a State Fair Hearing:

You have the right to ask for a State Fair Hearing if we denied your Medicaid service. You or your representative must ask for the State Fair Hearing within 120 days of the date on the Merdian (Medicare-Medicaid Plan) letter with the decision. If you do not ask for a State Fair Hearing within 120 days, you may lose your right to a fair hearing.

Part D Grievances & Appeals

Medicare Part D Coverage Determination Requests

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. You can ask us to make a coverage decision about the drug(s) or payment you need. This is known as a coverage determination.

Types of coverage determinations

Here are examples of coverage decisions you ask us to make about your Part D Drugs:

• You ask us to make an exception, including:

• Covering a Part D drug that is not on the plan's List of Covered Drugs (Formulary)

• Waiving a restriction on the plan's coverage for a drug (such as limits on the amount of the drug you can get)

• Paying a lower cost-sharing amount for a covered non-preferred drug

• You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the plan's List of Covered Drugs (Formulary) but we require you to get approval from us before we will cover it for you.)

• Please note: If your pharmacy tells you that your prescription cannot be filled as written, you will get a written notice explaining how to contact us to ask for a coverage decision

• You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.

Who can request coverage determinations?

To ask for a coverage determination, you, your doctor or someone else acting on your To ask for a coverage determination, you, your doctor or someone else acting on your behalf can request a coverage decision by calling, writing, or faxing us. If you are requesting an exception, your doctor or other prescriber must give us the medical reasons for the drug exception you are requesting. (We call this the "supporting statement.") Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing a written statement if necessary.

Timeframes for coverage determinations

A "Standard coverage decision," also called a "standard coverage determination" will be made within 72 hours. Generally, this means within 72 hours after we receive your request. If you are requesting an exception, we will give you our answer within 72 hours after we receive your doctor's statement supporting your request. We will give you our answer sooner if your health requires us to. When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines.

You can ask for a "fast coverage decision," also known as an "expedited coverage determination" if using the standard deadlines could cause serious harm to your health or hurt your ability to function. We must give you our answer within 24 hours. Generally, this means within 24 hours after we receive your request. If you are requesting an exception, we will give you our answer within 24 hours after we receive your doctor's statement supporting your request. We will give you our answer sooner if your health requires us to. You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you already bought.

If you are requesting payment for a drug you have already bought, we will give you an answer within 14 calendar days after we receive your request.

How to submit a coverage determination

We must accept any written request, including a request submitted on the Part D Coverage Determination Request Form. You, your patient or someone else acting on your patient's behalf can request a coverage determination by:

Phone:
1-855-323-4578
Monday – Sunday, 8 a.m. to 8 p.m.

Fax:
1-855-898-1487

Mail:
MeridianComplete- Appeal Coordinator
PO Box 44260
Detroit, MI 48244

Fax: 313-294-5552

Website: Submit a Part D Coverage Determination Request Form.

Part D Redeterminations

If you disagree with a coverage decision we have made, you can appeal our decision. This appeal is known as a redetermination.

Who can request redeterminations?

To ask for a redetermination, you, your patient or someone else acting on your patient’s behalf can request a redetermination by calling, writing, or faxing us.

Timeframes for redeterminations

A "Standard appeal," also called a "standard redetermination" will be made within 7 calendar days after we received your appeal. We will give you our answer sooner if your health requires us to. When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines.

You can ask for a "fast appeal," also known as an "expedited redetermination" if using the standard deadlines could cause serious harm to your health or hurt your ability to function. We must give you our answer within 72 hours after we receive your request. We will give you our answer sooner if your health requires us to. You cannot ask for a fast appeal if you are asking us to pay you back for a drug you already bought.

How to submit a redetermination

To ask for a redetermination, you must submit your request within 60 days from the date on the written notice we sent to tell you our answer on your request for a coverage decision. If you miss this deadline and have a good reason for missing it (like a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal), we may give you more time to make your appeal.

You have the right to ask us for a copy of the information regarding your appeal. If you wish, you and your doctor or other prescriber may give us additional information to support your appeal.

We must accept any written request, including a request submitted on the Part D Redetermination Request Form (PDF). You, your patient or someone else acting on your patient's behalf can request a redetermination by:

Phone:
1-855-580-1689
(Monday - Sunday, 8 a.m. to 8 p.m.)

Fax:
855-898-1487

Mail:
MeridianComplete-Appeals Coordinator
PO Box 44260
Detroit, MI 48244

Fax: 313-294-5552

Website: You can also submit a Part D Redetermination Request Form

Waiver of Liability (PDF) 08/14/2024

Provider Grievance & Appeals Process for Denied Claims

Contracted providers can request an appeal when acting strictly on their own behalf and the member is not at financial risk, such as for an unapproved inpatient admission. MeridianComplete's appeal process for these cases is independent of Medicare regulations and mirrors the non-Medicare provider appeal process.

MeridianComplete offers a post-service claim appeal process for disputes related to denial of payment for services rendered to MeridianComplete members. This process is available to all providers, regardless of whether they are in or out of network.

What Types of Issues Can Providers Appeal?

The appeals process is in place for two main types of issues:

1. The provider disagrees with a determination made by MeridianComplete, such as request for surgery or admission to a Skilled Nursing Facility.

2. The provider is requesting an exception to a MeridianComplete policy, such as prior authorization requirements. In this case, the provider must give an explanation of the circumstances and why the provider feels an exception is warranted in that specific case.

For Medicare, a treating provider may request a peer-to-peer discussion as part of an informal process to encourage dialogue between the requesting provider and MeridianComplete's physician reviewer. It is preferred that peer-to-peer discussion occur prior to a final decision. However, this process cannot be used to request a reconsideration of the initial adverse decision. Any request to change an initial adverse decision must be handled through the appeals process - not through a peer-to-peer discussion.

If you disagree with an adverse preapproval decision and wish it to be reconsidered, you must request an appeal by contacting MeridianComplete Member Services at 1-855-323-4578.

A provider's lack of knowledge of a member's eligibility or insurance coverage is not a valid basis for an appeal. Providers cannot appeal denials due to member ineligibility on the date of service or non-covered benefits.

How to File a Post-Service Claim Appeal

1. Please send a letter explaining the nature of your appeal and any special circumstances that you would like MeridianComplete to consider.

2. Attach a copy of the claim and documentation to support your position, such as medical records.

3. Send the appeal to the following address: By mail only

MeridianComplete
ATTN: Claims
P.O. Box 3060
Farmington, MO 63640

Timeframe for Filing a Post Service Appeal

Appeals must be filed within one year from the date of service.

MeridianComplete will allow an additional 120-day grace period from the date of the last claim denial, provided that the claim was submitted within one year of the date of service. Appeals submitted after the time frame has expired will not be reviewed.

Response to Post Service Claims Appeals

MeridianComplete typically responds to a post-service claim appeal within 60 days from the date of receipt. If additional information is needed, such as medical records, then MeridianComplete will respond within 30 days of receiving the necessary information. Providers will receive a letter with MeridianComplete's decision and rationale.

There is only one level of appeal available within MeridianComplete. All appeal determinations are final. If a provider disagrees with MeridianComplete's determination regarding an appeal, the in- or out-of-network provider may pursue the following option:

Binding Arbitration - A provider may initiate arbitration by making a written demand for arbitration to MeridianComplete. The Provider and MeridianComplete agree to mutually select an arbitrator and the process for resolution.

If you have any questions about the post-service claim appeal process, please call MeridianComplete Provider Services at 1-855-323-4578 for more information.

Denials and Appeals

All denial determinations are rendered by physicians. A nurse reviewer contacts the provider telephonically to inform them of the denial decision, reason for the denial and contact information to discuss the denial with our medical director. Written denial notification is sent via fax and mailed to the member. Treating physicians who would like to discuss a utilization review determination with the decision-making medical director may contact the MeridianComplete Utilization Management Department at 1-855-323-4578.

The written denial notification will include the reason for the denial, the reference to the benefit provision and/or clinical guideline on which the denial decision was based, and directions on how to obtain a copy of the reference. You may contact the Utilization Management Department any time at 1-855-323-4578, to request a copy of MeridianComplete's medical necessity guidelines.

Expedited Appeal

An expedited appeal is a request to change a denial decision for urgent care. Urgent care is any request for medical care or treatment with respect to which the application of the time period for making non-urgent care determinations could seriously jeopardize the life or health of the member or the member's ability to regain maximum function, based on a prudent layperson's judgment.

Inpatient services that are denied while a member is in the process of receiving the services are considered an urgent concurrent request and are therefore eligible for an expedited appeal.

Non-Urgent Pre-Service Appeal

Providers, acting on behalf of a member, may request an appeal of denial in advance of the member obtaining care or services.

MeridianComplete will provide acknowledgement of the appeal within three days of receipt of the request. No physician will be involved in an appeal for which he/she made the original Adverse Determination. No physician will render an appeal decision who is a subordinate of the physician making the original decision to deny.

Refer to the Billing and Payment section for directions on Post-Service Appeals.

TURN AROUND TIMES FOR PROCESSING PROVIDER APPEALS

Appeal Type	Makes Decision	Fax/Phone Notification	Written Notification
Expedited Appeal	Completed as expeditiously as the medical condition requires, but no later than 72 hours after the receipt Inpatient admissions are eligible if the member is receiving services at the time of the denial	Within 72 hours of the decision.	Within 72 hours of receipt of the request.
Pre-Service Appeals	Within 30 calendar days of receipt of the appeal.	Within 30 calendar days of receipt of the appeal.	Within 30 calendar days of receipt of the appeal.

Levels of Appeal/Grievance

The levels of the appeals process are listed below. If an appeal is not resolved at one level, it proceeds or can proceed to the next.

1. MeridianComplete Standard or Fast Appeals Process
2. Review by an Independent Review Entity (IRE)
3. Review by an Administrative Law Judge (ALJ)
4. Review by a Medicare Appeals Council (MAC)
5. Review by the Federal Court

Members can appeal a medical decision within 60 calendar days of receiving our letter denying the initial request for services or payment on their own behalf. They can also designate a representative, including a relative, friend, advocate, doctor or other person, to act for them. The member and the representative must sign and date a statement giving the representative legal permission to act on the member's behalf. This statement must be sent to MeridianComplete at:

MeridianComplete
ATTN: Claims
P.O. Box 3060
Farmington, MO 63640

Fax: 313-294-5552

Members should call MeridianComplete at 1-855-323-4578 (TTY 711), Monday - Friday from 8 a.m. - 8 p.m. to learn how to name an authorized representative.

Part D Grievances & Appeals

Medicare Part D Coverage Determination Requests

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. You can ask us to make a coverage decision about the drug(s) or payment you need. This is known as a coverage determination.

Types of coverage determinations

Here are examples of coverage decisions you ask us to make about your Part D Drugs:

• You ask us to make an exception, including:

• Covering a Part D drug that is not on the plan's List of Covered Drugs (Formulary)

• Waiving a restriction on the plan's coverage for a drug (such as limits on the amount of the drug you can get)

• Paying a lower cost-sharing amount for a covered non-preferred drug

• You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the plan's List of Covered Drugs (Formulary) but we require you to get approval from us before we will cover it for you.)

• Please note: If your pharmacy tells you that your prescription cannot be filled as written, you will get a written notice explaining how to contact us to ask for a coverage decision

• You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.

Who can request coverage determinations?

To ask for a coverage determination, you, your doctor or someone else acting on your To ask for a coverage determination, you, your doctor or someone else acting on your behalf can request a coverage decision by calling, writing, or faxing us. If you are requesting an exception, your doctor or other prescriber must give us the medical reasons for the drug exception you are requesting. (We call this the "supporting statement.") Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing a written statement if necessary.

Timeframes for coverage determinations

A "Standard coverage decision," also called a "standard coverage determination" will be made within 72 hours. Generally, this means within 72 hours after we receive your request. If you are requesting an exception, we will give you our answer within 72 hours after we receive your doctor's statement supporting your request. We will give you our answer sooner if your health requires us to. When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines.

You can ask for a "fast coverage decision," also known as an "expedited coverage determination" if using the standard deadlines could cause serious harm to your health or hurt your ability to function. We must give you our answer within 24 hours. Generally, this means within 24 hours after we receive your request. If you are requesting an exception, we will give you our answer within 24 hours after we receive your doctor's statement supporting your request. We will give you our answer sooner if your health requires us to. You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you already bought.

If you are requesting payment for a drug you have already bought, we will give you an answer within 14 calendar days after we receive your request.

How to submit a coverage determination

We must accept any written request, including a request submitted on the Part D Coverage Determination Request Form. You, your patient or someone else acting on your patient's behalf can request a coverage determination by:

Phone:
1-855-323-4578
Monday – Sunday, 8 a.m. to 8 p.m.

Fax:
1-855-898-1487

Mail:

MeridianComplete
ATTN: Claims
P.O. Box 3060
Farmington, MO 63640

Fax: 313-294-5552

Website: Submit a Part D Coverage Determination Request Form.

Part D Redeterminations

If you disagree with a coverage decision we have made, you can appeal our decision. This appeal is known as a redetermination.

Who can request redeterminations?

To ask for a redetermination, you, your patient or someone else acting on your patient’s behalf can request a redetermination by calling, writing, or faxing us.

Timeframes for redeterminations

A "Standard appeal," also called a "standard redetermination" will be made within 7 calendar days after we received your appeal. We will give you our answer sooner if your health requires us to. When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines.

You can ask for a "fast appeal," also known as an "expedited redetermination" if using the standard deadlines could cause serious harm to your health or hurt your ability to function. We must give you our answer within 72 hours after we receive your request. We will give you our answer sooner if your health requires us to. You cannot ask for a fast appeal if you are asking us to pay you back for a drug you already bought.

How to submit a redetermination

To ask for a redetermination, you must submit your request within 60 days from the date on the written notice we sent to tell you our answer on your request for a coverage decision. If you miss this deadline and have a good reason for missing it (like a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal), we may give you more time to make your appeal.

You have the right to ask us for a copy of the information regarding your appeal. If you wish, you and your doctor or other prescriber may give us additional information to support your appeal.

We must accept any written request, including a request submitted on the Part D Redetermination Request Form (PDF). You, your patient or someone else acting on your patient's behalf can request a redetermination by:

Phone:
1-855-580-1689
(Monday - Sunday, 8 a.m. to 8 p.m.)

Fax:
855-898-1487

Mail:

MeridianComplete
ATTN: Claims
P.O. Box 3060
Farmington, MO 63640

Fax: 313-294-5552

Website: You can also submit a Part D Redetermination Request Form