Observation Reconsideration Request | McLaren Health Plan Documents and Links

MHP Observation Reconsideration Request Form

Do you have documentation not previously submitted to McLaren Health Plan (MHP) that you believe supports an inpatient determination? MHP offers hospitals the opportunity to request a second clinical review of an observation decision. To start the reconsideration process, you need to complete the Reconsideration Request form at: McLarenHealthPlan.org/ReconsiderationForm

Forms must be submitted:

With new/additional documentation not submitted with the first clinical review.
Within 30 days of the observation determination date. Requests submitted outside of this time frame will not be accepted.
Prior to claim submission. If you have already filed a claim, you may NOT request reconsideration. See appeal language below.

Directions to file for reconsideration of an observation determination decision:

Complete the online form below or print and complete the Printable Observation Reconsideration Request Form.
Fax completed form along with the new/additional documentation to MHP at 810-600-7961 or mail to:

MHP will review the documentation and notify you of a final determination.*

Note: Fields marked with an * indicates required field

Reconsideration Request Form

Member Information

Member Last Name: *

Member First Name: *

Member ID: *

Member Date of Birth: *

Dates of Service: *

OBS Decision Date: *

Facility Name: *

Contact Information

Contact First Name: *

Contact Last Name: *

Contact Phone: *

Contact Email: *

New/additional documentation attached:

NOTE: File names for attachments must NOT contain special characters or spaces (dashes are allowed). Ex. file-smith.pdf

Did you upload new/additional documentation in the question above?: *

Yes
No

*If the treating physician would like to discuss this decision with our medical director, call 810-733-9721.

Appeal Rights: If you wish to dispute an action by MHP, the provider must complete and submit a Provider Request for Appeal form, available at McLarenHealthPlan.org. Attach a copy of the claim in paper form within 90 calendar days from the letter of Explanation of payment (EOP), original claim date of service, adjusted EOP or authorization decision. Mail the completed form and supporting documents to:

Thank you,
Medical Management