Appealing a denied authorization or Claim

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

To expedite any of these requests, complete the Provider Dispute Resolution Request form (33KB 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 have the opportunity to 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. 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 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