Appeal form l Priority Health Michigan Medicare insurance plans

Priority Health Medicare member appeal form

Use this form to file an appeal if you have received written notice that we made a coverage decision that was not in your favor. Learn more about asking for a coverage decision on this website or check your Evidence of Coverage booklet for complete details.

Personal info

Priority Health contract number:

First name:

Middle initial:

Last name:

Street address:

City:

State:

ZIP:

Phone number:

Provide details why our decision should be reconsidered:

Details:

Name of person filing appeal (if different from member)

First name:

Middle initial:

Last name:

Relationship to member:

Certification

E-signature:

I certify that this information is true to the best of my knowledge.

Print

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Corporate offices in Michigan

Farmington Hills:

34505 West 12 Mile Rd.

Farmington Hills,
Michigan 48331

Grand Rapids:

1231 East Beltline NE

Grand Rapids,
Michigan 49525

Holland:

250 East Eighth Street

Holland,
Michigan 49423

Jackson:

100 E Michigan Avenue

Suite 320

Jackson,
Michigan 49201

Kalamazoo:

8175 Creekside Drive

Portage,
Michigan 49024

Traverse City:

300 East Front Street

Suite 250

Traverse City,
Michigan 49684

Priority Health Medicare member appeal form

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Corporate offices in Michigan