Utilization Management (UM) Provider Appeals

Utilization Management (UM) Provider Appeals Policy

Attachment: Adequate Notice of Adverse Benefit Determination

Attachment: Adequate Notice of Adverse Benefit Determination (Non-Medicaid)

Attachment: Administrative Appeal Determination Form

Attachment: Administrative Appeal Determination Form (MHL)

Attachment: Administrative Denial Appeal Request Form

Attachment: Advance Notice of Adverse Benefit Determination

Attachment: Advance Notice of Adverse Benefit Determination (Non-Medicaid)

Attachment: Appointment of Representative Form

Attachment: DWIHN Access Center

Attachment: DWIHN Denial and Appeal Medical Necessity (MHL)

Attachment: DWIHN Prior Authorized Service UM Chart Review Tool

Attachment: Enrollee/Member Agreement for Additional Information Request

Attachment: IRO Physician Review

Attachment: IRO Referral Review

Attachment: Local Appeal Request Form (Medicaid)

Attachment: Local Appeal Request Form (MHL)

Attachment: Medicare Reconsideration Background Data Form

Attachment: Notice of Administrative Denial Form

Attachment: Notice of Administrative Denial Form (MHL)

Attachment: Notice of Appeal Approval

Attachment: Notice of Appeal Approval (MHL)

Attachment: Notice of Appeal Decision

Attachment: Notice of Appeal Denial

Attachment: Notice of Dismissal

Attachment: Notice of Receipt of Appeal

Attachment: Notice of Receipt of Appeal (MHL)

Attachment: Physician Letter

Attachment: Physician Letter (MHL)

Attachment: Post-Service UM Provider Appeals Procedures (Medicaid)

Attachment: Post-Service UM Provider Appeals Procedures (Medicare)