The provider appeals process below is intended to cover denials based on medical necessity where the provider is liable for the cost of care.
Also see appeals for non-certified mental health or substance abuse inpatient or partial hospitalization
The provider appeals process is handled through the Utilization Management Department as outlined below:
Level 1 Appeal
The case is reviewed with the Associate Vice President, Medical Affairs and/or the Medical Director and decision made within 30 days of receipt. Communication of the decision is sent to the provider by the Health Management Medical Specialist via telephone and letter. If the appeal is reviewed through an onsite Denial Management Meeting, verbal notification of the decision is binding. If the Associate Vice President, Medical Affairs and/or the Medical Director does not find an indication for overturning the denial, the provider has the right to a second level appeal upon written request within 30 days of receiving notice of the decision. When a denial is overturned, the Health Management Medical Specialist will send a Customer Service inquiry to Claims for payment.
Level II Appeal – Provider Appeal Committee – Appeal of Medical Necessity
The provider is informed of his/her option to a Level II appeal which involves review by the Provider Appeal Committee.
The Health Management Medical Specialist will present the appeal to the Priority Health Provider Appeal Committee. The decision of this committee is final. This committee has 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 Medical Affairs Committee
The committee will make a decision regarding the appeal within thirty (30) days of receipt and inform the practitioner/provider via letter of the outcome of the review.