Reviews & Level 1 appeals process
These processes do not apply to Priority Health Medicare member authorizations or claims.
Go to the instructions applicable under Medicare rules.
Informal review, medical
Deadline: Within one year of the date of service
Steps:
- Call the Provider Helpline.
- In medical reviews, Priority Health reviewers may:
- Make an immediate decision using the available information
- Consult medical directors for additional input
- Refer the case for independent peer review
- Refer the case to the Utilization Management/Quality Management Committee
- If you are not satisfied with the outcome of the informal review, you may file a Level I appeal (below).
Informal review, coding/claims
Deadline: Within one year of the date of service
Steps:
- Call the Provider Helpline or the Provider Payments Solutions Center.
- You should receive a response within two business days.
- If you are not satisfied with the outcome of the informal review, you may file a Level I appeal (below).
Appeal: Level I
Deadline: Within one year of the date of service
Steps:
- Complete a Level I appeal form (144KB PDF) and fax it to the address on the form.
- Include supporting documentation for your request. Go to documentation requirements.
- Submit the form and supporting notes or documents to the fax number/address on the form.
- Priority Health specialists will research and compile the contractual, benefit, claims and medical record information. The collected information will be used to construct a chronology of events with all pertinent dates.
- If Priority Health upholds the denial, you will be informed of the process you will need to file a Level II appeal.
