Skip to content Priority Health
Sections

Appealing a denied authorization or Claim

Jump to:

Categories of requests

After your authorization, claim or other payment has been denied, you have 30 days to appeal our decision. These requests for reconsideration fall into one of three categories:
  • Claim reconsideration: Clinical edit exceptions, claims denied for notes, and claims resubmitted with notes
  • Administrative appeals: Denials for timely filing, processing errors, interest payments, and clinical edits
  • Medical reviews: Services denied for authorization or medical necessity, DRG payments, benefit exception requests for service or drug that's not covered, and corrected diagnosis codes

Submit this form to expedite requests

Provider Dispute Resolution Request form (89KB PDF).

The dispute resolution process

  1. Informal review. When Priority Health has denied a claim, contact your Provider Representative for an informal review. If you are not satisfied with the outcome of the informal review, you may bring your concern to a formal review process.
  2. Level I review. To initiate a formal Level I review, complete a Provider Dispute Resolution Request form (above). Clearly mark the reason you are asking for a review so that processing will not be delayed.
    • You must include supporting documentation for us to review your request.
    • Mail the form and supporting notes or documents to the address on the form.
    • Priority Health specialists will research and compile the necessary contractual, benefit, claims and medical record information. The collected information will be used to construct a chronology of events with all pertinent dates.
    • If you are appealing a procedure that has been labeled "not medically necessary," your appeal will be forwarded to a Priority Health Team Manager for review.
    • The Medical Director who made the initial decision for further review will review the case. If the appeal is overturned, we will send you a letter. If the Medical Director does not find an indication for overturning the denial, then the information is sent to the Chief Medical Officer for review and decision within 30 days of receipt of the appeal.
    • If Priority Health upholds the denial, you will be informed of the process you will need to follow to file a Level II appeal.
  3. Level II appeals. You must appeal the Level I decision within 30 days. Complete a new Provider Dispute Resolution form (above) with any additional documentation and re-submit it to the address on the form.

    Appropriate Priority Health directors, officers, and/or third-party consultants will make a decision on your Level II appeal within 30 days of receipt and inform you of the outcome of the review by letter within five working days of the decision.

    This decision is final.

    In medical reviews, Priority Health reviewers have the following options:
    • 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 UM/QM committee

Non-contracted Medicare providers only

The Centers for Medicare & Medicaid Services (CMS) has expanded its provider payment dispute resolution process to include Medicare Advantage Organizations (MAOs), which includes Priority Health.

"Non-contracted Medicare providers" are defined by CMS as "providers who are not sanctioned by CMS or considered opt-out for Medicare payment purposes and who have not agreed to participate with Original Medicare and/or a Priority Health Medicare Advantage (MA) plan."

Plans included

The CMS process applies to Medicare-covered medical services and supplies for patients covered by: 
  • PriorityMedicare ValueSM (HMOPOS)
  • PriorityMedicareSM (HMOPOS)
  • PriorityMedicare PlusSM (HMOPOS)
  • PriorityMedicare ChoiceSM (PPO)
  • PriorityMedicare (Employer group HMOPOS)
  • PriorityMedicare Choice (Employer group PPO)

Exclusions

This process may not be used to:
  • Challenge payment denials by Priority Health Medicare that result in zero payment.
  • Resolve payment disputes between contracted providers and Priority Health Medicare.

Process steps

  1. Follow the Priority Health provider dispute resolution process above.
  2. The CMS provider payment dispute resolution process begins after:
    • Priority Health makes an initial dispute decision about an initial payment dispute filed by a non-contracted provider. Then the provider has the right to request an independent payment dispute decision (PDD) from the CMS Payment Dispute Resolution Contractor, First Coast Service Options, Inc. (FCSO).
    • Priority Health fails to make an initial payment dispute decision in response to a non-contracted provider dispute resolution request within 30 days from the date the request was received. Then the provider may request a payment dispute decision (PDD) without having received an initial dispute decision. The provider must provide evidence to FCSO of the dispute filed (including the date filed).

Where to submit a dispute/request a dispute decision

  • E-mail: PDRC@FCSO.com
  • Fax: 904 361-0551
  • Mail: First Coast Service Options, Inc.
    Payment Dispute Resolution Contractor
    P.O. Box 44017
    Jacksonville, Florida 32231-4017

Contacting a CMS payment dispute resolution contractor

If you have any questions about the adjudication process, contact a CMS Payment Dispute Resolution Contractor through FCSO.
  • Telephone: 904 791-6430
    Providers and organizations will be able to leave messages and should expect a return call within two business days.
  • Mail: First Coast Service Options, Inc.
    Payment Dispute Resolution Contractor
    P.O. Box 44035
    Jacksonville, Florida 32231-4035

Last modified 06/14/10