How to file a Medicare appeal

Either an "appeal" or a "request for drug redetermination" is how you ask Priority Health to reconsider when your request for a Medicare coverage decision has been turned down. See below for how to file an appeal.

If you haven't formally asked for a coverage decision yet, go to instructions.


Making an appeal or requesting a drug redetermination

  • There are five levels of this process.
  • At each level, your request is considered again and a new decision made.
  • The decision may be all or partly in your favor, or all against you.
  • If you are unhappy with the decision, you may be able to ask for the next level. Refer to your Evidence of Coverage (EOC) for details about the five levels of appeal.

Follow these steps:

  1. Decide if you want someone else, like a spouse, child, or friend, to make an appeal for you. This person will be your "authorized representative."
    Go to the instructions for naming an authorized representative.
  2. Give us the reasons why you think we should reconsider our decision. Use one of these ways:
    Medical appeals Drug redeterminations

    - Fill out our online form, or
    - Write us a letter, or
    - Print the appeal form, complete it and fax or mail it to us:

    Appeal form to appeal a medical service coverage decision (PDF)

    - Call Customer Service at 888.389.6648 (TTY 711) from 8 a.m. to 8 p.m., seven days a week, or
    - Print this redetermination form, complete it and fax or mail it to us:

    Request for redetermination of Medicare prescription drug denial (PDF)

  3. Submit your form online, or mail your letter or form (and your authorization for your representative to act for you, if any) to:
    Medical appeals Drug redeterminations
    Priority Health Medicare Appeal Coordinator
    MS 1150
    1231 East Beltline NE
    Grand Rapids, MI 49525
    Fax: 616.975.8827
    Part D Appeal Coordinator
    MS 1260
    Priority Health Pharmacy Department
    1231 East Beltline NE
    Grand Rapids, MI 49525
    Fax: 877.974.4411
    You can also deliver it in person, or call Customer Service for help.
  4. To check on the status of your appeal or to learn more about the appeals process, call Customer Service from 8 a.m. to 8 p.m., seven days a week, at 888.389.6648 (TTY 711). See your "Evidence of Coverage" booklet (links below) for ways to ask for a "fast decision" or "72-hour decision."

Evidence of Coverage (EOC)

The Evidence of Coverage is the legal, detailed description of benefits and costs for the plan year. It explains the rights and rules you will need to follow when using coverage for medical care and prescription drugs. It also provides details about all five levels of an appeal.

Download EOCs