How to file a Medicare appeal

Either an "appeal" or a "request for drug redetermination" is how you ask Priority Health to reconsider when your request for a Medicare coverage decision has been turned down. See below for how to file an appeal.

If you haven't formally asked for a coverage decision yet, go to instructions.

Making an appeal or requesting a drug redetermination

• There are five levels of this process.
• At each level, your request is considered again and a new decision 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.

Follow these steps:

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. Give us the reasons why you think we should reconsider our decision. Use one of these ways:
   
   

   Medical appeals	Requests for drug redeterminations
   Fill out our online form, or  Write us a letter, or Print this form, complete it and fax or mail it to us. Appeal Form to appeal a medical service coverage decision (15KB PDF)	Print this form, complete it and fax or mail it to us. Request for Redetermination of Medicare Prescription Drug Denial (656KB PDF)

   
   
3. Submit your form online, or mail your letter or form (and your authorization for your representative to act for you, if any) to:

   Priority Health Medicare Appeal Coordinator
   MS 1150
   1231 East Beltline NE
   Grand Rapids, MI 49525
   Fax: 616 975-8827
   
   You can also deliver it in person, or call Customer Service for help.

4. To check on the status of your appeal or to learn more about the appeals process, call Customer Service from 8 a.m. to 8 p.m., 7 days a week, at 888 389-6648. TTY users should call 711. See your "Evidence of Coverage" booklet (links below) for ways to ask for a "fast decision" or "72-hour decision."

For complete details, see your Evidence of Coverage booklet.

The information above is a summary of the full explanation and instructions for making appeals in your plan's Evidence of Coverage booklet. For more complete instructions, use the links below to open your plan's booklet.

• 2012 PriorityMedicare Value Evidence of Coverage booklet (925KB PDF)*   Go to Chapter 9 (page 143).
  Form number: H2320_1002_1027_18 File and Use 09122011
• 2012 PriorityMedicare Evidence of Coverage booklet (2.2MB PDF)*   Go to Chapter 9 (page 145).
  Form number: H2320_1002_1027_18 File and Use 09122011
• 2012 PriorityMedicare Select Evidence of Coverage booklet (1.8MB PDF)*   Go to Chapter 9 (page 141).
  Form number: H2320_1002_1027_19 File and Use 09122011
• 2012 PriorityMedicare Rx Evidence of Coverage booklet (1MB PDF)*   Go to Chapter 7 (page 85).
  Form number: H2320_1002_1027_18 File and Use 09122011