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Member Appeals

Asking Us to Reconsider a Decision

We understand that you may disagree with a decision that we make.  We make decisions about resolving complaints and we make decisions about authorizing coverage for care or treatment.  When we make these decisions, we make every effort to avoid disagreements.  If you do not agree with our decision, you may appeal.  We will tell you about how to appeal decisions we make as part of the resolution process.  This includes how to appeal our decisions that might have a negative impact on your coverage or benefits or our relationship.  We will also help you with the appeal process.  An appeal is your request to us to change our decision about a complaint resolution or coverage for care or treatment issue.

When BHPI makes decisions about complaints or authorizing coverage for care or treatment, we will tell you about how you can appeal the decision.  If you are unhappy with the decision, you may file an appeal.  Call, write, or fax us your appeal.  

Behavioral Health Professionals, Inc.

Complaint and Appeals Coordinator

1333 Brewery Park Blvd, Suite 300

Detroit, MI 48207


Member Services (888) 711-5465

Fax Number (313) 656-2588

 

If you need language assistance to help you file an appeal, let us know.  We will provide language assistance at no cost to you.  We have bilingual staff and an interpreter service available for the entire process.  Upon request, we can provide oral interpretation of documents written in English into your preferred language or translation of written documents into your preferred language.  Finding the best way to resolve your appeal is an important part of our quality improvement program. 

We will investigate the issues thoroughly.  The staff involved in the investigation will not be the same as the individual(s) who made the first decision.

We determine the best people to investigate an appeal based on the nature of the appeal.  The Complaints and Appeals Coordinator will oversee the process.  When appeals are of a clinical nature, an appeal reviewer(s) who is a clinician and who was not involved in the original decision investigates the issues and proposes a resolution.  

We propose resolutions to routine appeals within 30 calendar days and notify you of the decision.  We propose resolutions to clinically urgent appeals within 72 hours and notify you of the decision. 

For appeals of proposed complaint resolutions, the appeal decision is final and there is no second level of appeal. 

UM Appeals

There are three types of appeals for adverse determinations based on medical necessity, clinical appropriateness, benefit limitations and administrative criteria.

  • Standard Pre-Service Appeal.
  • Expedited Pre-Service Appeal.
  • Post-Service Appeal.

Standard pre-service appeals of UM adverse determinations are available when BHPI does not approve, in whole or in part, a request for care or service in advance of you receiving the care or service.  Standard pre-service appeals are resolved and notification sent to you and your practitioner within 30 calendar days of the date BHPI  received the request for the appeal.

Expedited pre-service appeals of UM adverse determinations are available when, in the opinion of a practitioner with knowledge of your condition, the adverse determination would subject you to adverse health consequences without the care or treatment that is the subject of the request.  Expedited appeals are resolved and notification sent you and your practitioner within 72 hours of when BHPI 

received the request for the appeal or sooner if your condition requires.

Post service appeals of UM adverse determinations are available if you have already received the care or service that is the subject of the appeal.   Post-service appeals are resolved and notification sent to you and your practitioner within 60 calendar days of the date BHPI received the request for the appeal.

The appeal is conducted by one or more appeal reviewers who were not involved in the UM adverse determination that is the subject of the appeal.  The appeal reviewer thoroughly investigates the substance of the appeal, including any aspects of clinical care involved, and may request additional material such as medical records. 

BHPI has an external appeal process for UM adverse determinations.  At any time in the appeal process you may request an external appeal by contacting:

At any time in the appeal process you may have a representative participate in the appeal process on your behalf.  You may submit written comments or documents that relate to the appeal.  You may have copies of all documents pertaining to the appeal, upon request and at no cost to you.  

Behavioral Health Professionals, Inc.

Complaint and Appeals Coordinator

1333 Brewery Park Blvd, Suite 300

Detroit, MI 48207