Denial of Service

Denial of Service Policy

Attachment: Adequate Notice of Adverse Benefit Determination Form Medicaid SMI IDD SUD

Attachment: Adequate Notice of Adverse Benefit Determination Form Uninsured or Under Insured

Attachment: Advance Notice of Adverse Benefit Determination Form Uninsured or Under Insured

Attachment: Advance Notice of Benefit Determination Form Medicaid SMI, IDD, SUD.

Attachment: Appointment of Representative Form

Attachment: Denial Audit Tool

Attachment: Denial of Medicaid Service Procedures

Attachment: Denial of Service Procedures for the Uninsured or Under Insured

Attachment: DWIHN Access Center

Attachment: DWIHN Prior Authorized Service UM Chart Review Tool

Attachment: Enrollee Agreement for Request for Additional Information Form (Medicaid SMI, IDD, SUD)

Attachment: Enrollee Agreement for Request for Additional Information Form (MHL)

Attachment: Enrollee Agreement for Request for Additional Information Form (Uninsured or Under Unsured)

Attachment: IRO Physician Review

Attachment: IRO Referral Review

Attachment: MI Health Link Denial of Services Procedure

Attachment: Notice of Administrative Denial (MHL)

Attachment: Notice of Administrative Denial (Medicaid SMI, IDD, SUD)

Attachment: Notice of Administrative Denial Form (Uninsured or Under Insured)

Attachment: Notice of Denial of Medical Coverage MHL

Attachment: Physician Letter (Medicare SMI, IDD, SUD)

Attachment: Physician Letter (MHL)

Attachment: Physician Letter (Uninsured or UnderInsured)

Attachment: Request for Addition (Uninsured or Under Insured)

Attachment: Request for Additional Info (Medicaid SMI, IDD, SUD)

Attachment: Request for Additional Info MHL

Attachment: UM Decision Turn Around Times for Initial Determinations