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. The member appeals process consists of the following steps:

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Fully Funded and Government Programs (except Medicare)

Step 1: The member contacts the Customer Service Department and completes a Grievance Form. The grievance is reviewed by the Grievance Committee that consists of Priority Health employees and a physician. The grievance and any information gathered from health care providers and facilities will be reviewed by the Grievance Committee. The Grievance Committee meets every 7 days or more frequently in order to respond in a timely manner.

Step 2: The member may appeal the decision of the Grievance Committee if he or she is not satisfied by completing an Appeal Form. This level of appeal is reviewed by the Appeals Committee, which may include Priority Health members, local employers that offer Priority Health to their employees, physicians from the Priority Health network and Priority Health employees. Review by the Appeals Committee includes an opinion from a physician in the same or related specialty for health issues. The member or an authorized representative (including a physician) that the member has chosen has the option of being present for the review or to participate by a conference call or another form of technology. The Appeals Committee meets every 7 days or more frequently in order to respond in a timely manner.

The following timelines apply for members with fully funded HMO/POS/PPO coverage or Medicaid/MIChild coverage:

Pre-service timeline: The grievance and appeal steps combined must be completed with a final determination made within a total of 30 calendar days after the formal grievance and appeal forms have been received. The 30 day count does not include any days the member, or the member's authorized representative acting on behalf of the member, may delay the procedure. Neither the grievance step nor the appeal step may take more than 15 days, respectively.

Post-service timeline: The grievance and appeal steps combined must be completed with a final determination made within a total of 35 calendar days after the formal grievance and appeal forms have been received. The 35 day count does not include any days the member, or the member's authorized representative acting on behalf of the member, may delay the procedure. Neither the grievance step nor the appeal step may take more than 30 days, respectively.

Step 3: If steps 1 and 2 have been completed and the member remains dissatisfied with the decision, the member may request an external review through the Office of Financial and Insurance Regulation (OFIR). The member has 60 days to make this request after receiving the final determination from the Appeal Committee. If the review request is accepted by the state, an Independent Review Organization (IRO) is asked to perform the review for medical issues. Non-medical contractual issues may be reviewed by the Commissioner of OFIR and/or an IRO.

Expedited Review: This review is performed when the service being requested is considered to be urgent and a delay in decision-making would put the member's life in danger, would interfere with the member's full recovery or would subject the member to severe pain. The decision for an expedited review will be made within a total of 72 hours after receiving the request(s). If the member is not satisfied with this response, they can appeal to the State of Michigan within 10 days after receiving the final decision from Priority Health.

Members with Medicaid coverage also have the right to request a Fair Hearing with the State of Michigan before, during or after completing Priority Health's internal appeals process listed above.

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: Reconsideration by Priority Health: An enrollee (or an enrollee's authorized representative) may submit (orally or in writing) an appeal to Priority Health, his/her Social Security Administration office or in the case of a qualified Railroad Retirement Board (RRB) beneficiary, an RRB office, within 60 days after Priority Health notifies the member of the organization determination. The appeal is reviewed by the Appeals Committee.  All determinations are made by at least one physician member of the Appeals Committee that has the expertise in the field of medicine that is appropriate for the services at issue. The non-physician members of the Appeals Committee may participate in the review of the case; however, the physician(s) reviewing the case is the only decision maker. The member or an authorized representative that the member has chosen has the option of attending (in person, by conference call, etc.) the Appeal Committee to present his or her position. The Appeal Committee meets every 14 days or more often in order to respond in a timely manner.

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.