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IMPORTANT NO TICE
Your appeal rights
You can resolve most quesons about our payment decisions by calling our Member Service Center at 800.336.0013 or
TTY 888.445.5614. If you sll have concerns, you have the right to le a grievance with us and to request an external
review with the Department of Insurance and Financial Services. We briey explain these procedures below. For
further details regarding the grievance process, call our Legal and Compliance Department at 800.742.2328 or visit our
website at www.messa.org.
MESSA Grievance Procedure
Write to us to tell us why you disagree with our decision. You must complete our standard grievance procedure
before you can request an external review. Please include your enrollee idencaon number, dayme telephone
number, date of service and any informaon that might support your posion. If you want another person, including
a physician, to act on your behalf during this grievance procedure, please include wrien authorizaon. Mail your
grievance to:
Associate Manager, Legal and Compliance
MESSA
1475 Kendale Blvd., P.O. Box 2560
East Lansing, MI 48826-2560
If you disagreed with our decision not to preapprove a service, we will send our nal wrien determinaon within 15
days of the date we received your grievance. If you disagreed with our claim denial or payment decision, we will send
our nal wrien determinaon within 30 days of the date we received your grievance. These periods suspend for any
me you take to respond to us. In both cases, you have the right to allow us addional me and we are allowed 10
addional days if we need more informaon from your healthcare provider. If you sll disagree with our decision, you
may request an informal managerial-level conference to discuss your grievance with us.
External Review Procedure
If our response doesn’t sasfy you, or if we don’t respond within 30 days regarding a preapproved service or 60 days
regarding a claim denial or payment decision, you can request an external review with the Department of Insurance
and Financial Services. You must request this review in wring within 120 days of receiving our nal determinaon.
You will have to authorize the release of protected health informaon during this external review. The Department’s
decision is final.
1475 Kendale Blvd., P.O. Box 2560 East Lansing, Michigan 48826-2560 517.332.2581 800.292.4910
Member Appeal Form
Mailing address:
Associate Manager, Legal and Compliance
MESSA
1475 Kendale Boulevard, P.O. Box 2560
East Lansing, MI 48826-2560
800.292.4910
Fax: 517.203.2909
Enrollee/Paent Informaon Secon
Enrollee’s name
Date of service
Type of service
Your signature Date
To assist us in reviewing your appeal, please summarize the issue and acon desired below, and aach all supporng documentaon.
Provider name
Locaon of service
Paent’s name (if dierent from enrollee)
Address City State ZIP code
Relaonship to enrollee Dayme telephone number
Self Spouse Dependent
Enrollee ID Group number
Claim Detail Secon
Rev. 2/23/17
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Completed 14 April 2022

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