How to appeal our decisions

How to file an appeal with PriorityMedicare^SM

What is an appeal

After you have formally asked for an exception to what drugs and services we cover under your PriorityMedicare plan (see instructions for requesting an exception) and we have made a decision not to cover what you ask for, you can ask us to reconsider your request. This is called an appeal. See below for how to file an appeal.

A complaint about Priority Health, its services and employees, 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.

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Making an appeal

If you believe that a certain drug or service should be covered for you, but we made a decision to deny your request, you can appeal our initial decision.

• There are five levels of the appeals process.
• 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.

Follow these steps to file an appeal:

1. 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." Go to the instructions for naming an authorized representative.
2. 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.
3. State the reasons why you think we should reconsider our decision.
4. 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 1145
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 below) for ways to ask for a "fast decision" or "72-hour decision."
   

For complete details

The information on this page is a summary of the full explanation and instructions for making appeals in your plan's Evidence of Coverage booklet. For longer, more complete instructions, go to:

• Evidence of Coverage for PriorityMedicare Value^SM plan, (715KB PDF)
• Evidence of Coverage for PriorityMedicare^SM plan, (754KB PDF)
• Evidence of Coverage for PriorityMedicare Plus^SM plan, (728KB PDF)
• Evidence of Coverage for PriorityMedicare Rx^SM plan, (506KB PDF)

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