May 2024
Michigan acute inpatient facilities should submit peer-to-peer review requests, appeals through the e-referral system
Acute inpatient facilities in Michigan should use the e-referral system to submit peer-to-peer review requests and appeals related to prior authorization requests for inpatient acute care medical and surgical (non-behavioral health) admissions. Submitting these requests through the e-referral system involves completing questionnaires and attaching clinical documentation when applicable.
Submitting through the e-referral system offers a streamlined process that:
- Can help you meet submission deadlines and get faster responses
- Allows you to see initial prior authorization requests, peer-to-peer review requests and appeals in the same location
- Prevents the need to search through emails, wonder if a fax went through or call to confirm that a request was received
Here are some resources you can use to learn more:
- The How to request a peer-to-peer review with a Blue Cross or BCN medical director document. We’ve updated it to include details you’ll need to know about using the e-referral system. In the table under Non-behavioral health services, look for the row labeled Inpatient non-behavioral health non‑elective admissions — in acute care hospitals for medical and surgical admissions.
- The Submitting requests for appeals and peer-to-peer reviews in e‑referral training course. For instructions on accessing this course, refer to this article in the March 2024 issue of The Record.
- The e-referral User Guide. Look in the section titled "Submit an inpatient authorization."
When the e-referral system is not available, you can:
You can’t use the e-referral system to submit a peer-to-peer review request or appeal for prior authorization requests that:
- Were submitted prior to the member’s admission
- Were administratively denied
- Are for inpatient behavioral health admissions
- Are for outpatient medical, surgical or behavioral health services
- Are for inpatient hospital clinical edit denials, pre-service denials, post-service audit overturns, post-claim bundling and claim denials
- Are for professional service authorization denials
- Are for denials made by a vendor
Non-Michigan facilities can’t use the e-referral system to submit peer-to-peer review or appeal requests. They must continue to:
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