Receive and review your final appeal decision letter.
Once you receive this letter from the MCO, and the reason listed is related to medical necessity, you can file your case with Maximus.
Visit the Maximus web portal.
You have 30 calendar days from the date of the final appeal decision letter to file a case.
The entire review process is online. Once you register an account, you must sign and upload a case review agreement. From there, you can upload your final appeals decision letter. Maximus will request the appeals record from the MCO. Once the MCO sends the record, Maximus will resolve the dispute within 30 calendar days.
Download the Quick Reference Guide in the References and Resources section to learn how to use the portal to file cases, review past cases, make payments, and more.
How much does it cost
to file a case with Maximus?
During the initial year of the contract, the review fee is $325 per case. The case review fee will increase by $10 each subsequent year on the 15th of October. Please see fee schedule below.
Annual Fee Increase Schedule
Oct. 15, 2019 - Oct. 14, 2020: $325
Oct. 15, 2020 - Oct. 14, 2021: $335
Oct. 15, 2021 - Oct. 14, 2022: $345
Oct. 15, 2022 - Oct. 14, 2023: $355
Oct. 15, 2023 - Oct. 14, 2024: $365
Maximus only charges after making the case determination. If Maximus upholds the MCO’s denial, you must pay the fee. If Maximus reverses the MCO’s denial, the MCO must pay the fee. The web portal will walk you through submitting payments.
What cases do not qualify
for independent review?
Maximus will not accept:
Bundled claims with similar issues
Cases that have not completed all levels of internal MCO appeals (If you fail to meet the MCO internal appeals deadlines, Maximus will not review your case.)
Claims unrelated to HealthChoice recipients
What if I disagree
with the determination from Maximus?
If you choose to use this review process, you agree to give up all appeal rights (e.g., administrative hearings, court cases).
What if I have a medical necessity case that involves behavioral health?