The Provider Appeal Process offers prompt review of claims that are initially denied or claims where the Provider disputes the payment amount (For claims related to CodeReview please see Section 4, Subsection D of the Provider Manual). A Provider has sixty (60) days from the date of the denial or receipt of payment from DMC Care to initiate the appeal process.

If the Provider decides to appeal, all pertinent information and the reason(s) you believe your claim should be reconsidered must be included in the request. Your appeal information should be mailed to the Appeals Coordinator at:

DMC Care
Claim Appeals
P.O. Box 44290
Detroit, MI 48244

After receiving your appeal request DMC Care Health Plan will render a decision based on applicable policy and procedures and any information submitted by the provider within sixty (60) days of receiving your request.

Providers who are denied at Level I have the option of appealing at Level II. All Level II appeals should be submitted with additional documentation and rational within fifteen (15) days of notification of Level I denial. The Benefit Interpretation Committee will provide investigate review and forward to the Quality Utilization Management Committee for final decision.

The Appeals Coordinator will send written notification of decision to the provider within forty-five (45) days of Level II appeal decision.