Provider Appeals

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 of medical affairs or a medical director and decision made within 30 days of receipt. Communication of the decision is sent to the provider by the senior 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 of medical affairs and/or medical director does not find an indication for overturning the denial, the provider has the right to a second level appeal upon written request.  When a denial is overturned, the senior health management medical specialist will send a Customer Service inquiry to Claims for payment.

Level II Appeal
The case is reviewed with the chief medical officer and decision made within 30 days of receipt.  Communication of the decision is sent to the provider by the senior health management medical specialist via telephone and letter.  If the chief medical officer does not find an indication for overturning the denial, the provider shall be informed of his/her option to appeal to the Provider Appeal Committee.  When a denial is overturned, the senior health management medical specialist will send a Customer Service inquiry to Claims for payment.
 
Provider Appeals Committee - Appeal of Medical Necessity
Provider appeals of the Level I and II decision must be made within 10 business days to the senior health management medical specialist, who will present the appeal to the Priority Health Provider Appeals Committee.  The committee is composed of at least 3 individuals including the director of network expansion and sService, a Health Management (clinician) representative, and associate vice president of clinical quality improvement.  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 30 days of receipt and inform the practitioner/provider via letter of the outcome of the review.