The information on this page is a summary of the full explanation and
instructions in your plan's Evidence of Coverage booklet. For longer, more
complete instructions, go to:
What are Appeals and Grievances?
Federal law guarantees that you can make a formal complaint if you have
concerns or problems with any part of your care. The Medicare program has
helped set the rules about what you need to do to make a complaint, and what
we are required to do when we receive your complaint. If you make a
complaint, we must be fair in how we handle it. You cannot be disenrolled
from a
PriorityMedicare plan or penalized in any way if you make a
complaint.
A complaint about what your plan will and will not cover for you, drugs or
medical services, is called an "appeal." See below for how to file an
appeal.
A complaint about Priority Health, or its doctors, pharmacies, hospitals,
or other health care providers, is called a "grievance."
Learn
about how to file a grievance about the service you receive.
Making An Appeal
First, Request an Initial Coverage Decision
If your doctor or pharmacist tells you that a certain drug or service is
not covered and you believe it should be covered for you, your first step is
to ask for an "initial decision" (use the
instructions
for requesting an exception). We will send you an initial decision in
writing within 72 hours.
Then You Can Make An Appeal
"Appeals" are a type of complaint you make when you want us to
reconsider and change a decision we have made about what benefits are
covered for you or what we will pay.
- If our initial decision is to deny your request, you can appeal our
initial decision.
- There are five levels of the appeals process after we make an
initial decision not to cover a drug or service for you.
- At each level, your request is considered again and a new decision is
made.
- The decision may be all or partly in your favor, or all against
you.
- If you are unhappy with the decision, you may be able to ask for the
next level of appeal.
What to do to file an appeal:
- Decide if you want someone else, like a spouse, child, or friend, to
make an appeal for you. This person will be your "authorized
representative." See
the instructions for naming an authorized representative.
- You or your authorized representative may write us a letter telling us
that you want to appeal our decision. Include your name, member ID number,
and a daytime phone number where we can reach you or your authorized
representative.
- State the reasons why you think we should reconsider our decision.
- Mail your appeal letter (and your form authorizing your representative
to act for you, if any) to:
Priority Health Appeal
Coordinator
1231 East Beltline NE
MS 3245
Grand Rapids, MI 49525
You can also deliver it in person, or
fax it to us at 616 942-0886, or
call
Customer Service for help.
5. To learn more about the appeals process or to check on the status of
your appeal,
call Customer Service and ask
to speak to an appeals coordinator.
See your Evidence of Coverage booklet (links at the top of this page) for
ways to ask for a "fast decision" or "72-hour decision."
