Schedule K Policy Appeals Processes.docx

This is a policy document issued by the State of Michigan under RFP No. 200000001290 that establishes appeals processes for the Michigan Public School Employees' Retirement System (MPSERS) non-Medicare member benefits. The policy, effective February 27, 2012, governs the administration of appeals for MPSERS Medical, Prescription Drug, Dental, and Vision plans and applies exclusively to non-Medicare enrolled members. The document outlines a two-level appeals structure for medical, dental, and vision claims, where members first submit grievances to their respective medical vendors and may escalate to a second-level managerial conference where they can appear in person with representation. For prescription drug claims, members follow a similar two-tier process through their prescription vendors, with the first level handled by the vendor and the second level involving a managerial review conference with in-person appearance and representation options.

The policy specifies that MPSERS is not subject to the Patient Protection and Affordable Care Act (PPACA) and that independent external review outside the insurance company does not exist for these self-funded plans. Members who exhaust the internal appeals process may contact the Office of Retirement Services (ORS) or pursue litigation. The Attorney General determined that Michigan Public Act 251 is not applicable to MPSERS self-funded plans. Pre-service appeals for prior authorization and tier exceptions may be initiated before claim rejection, while post-service prescription appeals require point-of-sale denial messages. All respective insurance carriers administer the appeals processes and are responsible for directing member requests appropriately.