Member appeals
The member appeals process is handled through the Customer Service and the Legal Departments and is referred to as a member grievance or appeal.
Fully Funded
To see the fully funded commercial product grievance and appeals process, go to the Member "Contact us" section of this website.
Medicaid and MIChild
View the Medicaid and MIChild grievance and appeals process (69KB PDF).
Medicare
Following an adverse organization determination (also referred to as an initial decision), the appeals process may include 5 possible steps for members enrolled in our Medicare products.
Step 1: This step is explained in the Member "Contact us" section of this website.
The remaining four steps of the Medicare appeals process take place outside of Priority Health:
Step 2: Reconsideration by an Independent Review Entity (IRE)
Step 3: Hearing by an Administrative Law Judge (ALJ)
Step 4: Departmental Appeals Board (DAB) Review
Step 5: Judicial review
The Medicare appeals process has strict timelines (standard and expedited) for each step that have been established by CMS. Priority Health has policies and procedures in place to ensure this these timelines are met.
