If we make a coverage decision, whether before or after you get a benefit, and you aren’t satisfied, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we made. Under certain circumstances, you can ask for an expedited or fast appeal of a coverage decision. Your appeal is handled by different reviewers than those who made the original decision.
When you appeal a decision for the first time, this is called a Level 1 appeal. There is a total of five levels of appeal that you may be able to continue through if you aren’t satisfied with our decision. Additional details can be found in Chapter 9 of your plan’s Evidence of Coverage.
An appeal request must be made within 65 calendar days from the date on the written notice we sent to tell you our answer on the coverage decision.
Medical Reconsiderations
An appeal to our plan about medical care coverage is called a plan reconsideration; includes both medical services, items you’re planning to receive; or payment decisions on services or items you’ve already had.
How to file an appeal
For standard medical appeals, submit a request in writing to give us the reasons why you think we should reconsider our decision. You can write us a letter, or use the following forms to make sure you’re giving us all the information we need:
- Fill out our online form, or
- Print and complete the medical care appeal form (PDF), then send to us:
Priority Health Medicare Appeals
1231 East Beltline NE, MS 1150
Grand Rapids, MI 49525 - You can also deliver it in person, or fax it to us at 616.975.8827
For expedited (fast) appeals, call the Customer Care team or submit your request in writing using the above methods. To get an expedited appeal, you must meet 2 requirements:
Your appeal request is for medical items and/or services that do not involve payment decisions.
You can get a fast appeal if using the standard review timeframe could cause serious harm to your health or hurt your ability to regain function.
For appeal requests involving Part B medical drugs, see the Drug Redeterminations section below.
When you’ll hear from us
For standard reviews, we must make a decision within 30 calendar days for standard requests involving medical services or items, and 60 calendar days for payment reviews.
For accepted expedited (fast) reviews, we must make a decision within 72 hours of receiving your request
Drug Redeterminations
An appeal to our plan about an adverse Part D drug or Part B medical drug coverage decision is called a plan redetermination. It includes both decisions on coverage for drugs you have not yet received and payment decisions on drugs you’ve already received.
How to file an appeal
For both Part B medical drugs and Part D Drugs, to submit standard and expedited appeals –
- Call the Customer Care team for assistance in submitting your request.
- You can write us a letter or use the Request for redetermination of Medicare prescription drug denial(PDF) form to help make sure you’re giving us all the information we need to review your request. Either mail or fax your request to us:
Priority Health Pharmacy Appeal Team
MS 1260
1231 East Beltline NE
Grand Rapids, MI 49525
Fax: 877.974.4411
For expedited (fast) appeals, call the Customer Care team or submit your request in writing using the above methods. To get an expedited appeal, you must meet 2 requirements:
- You may only ask for coverage for a Part D or Part B medical drug that you have not already received
- You can get a fast appeal only if using the standard deadlines could cause serious harm to your health or hurt your ability to regain function.
When you’ll hear from us
- For standard Part B medical drug or Part D drug reviews, we must make a decision within 7 calendar days of receiving your request.
- For payment reviews, we must make a decision within 14 calendar days of receiving your request.
- For accepted expedited (fast) reviews, we must make a decision within 72 hours of receiving your request.
Appointment of Representative
If you want someone else, like a family member or friend, to act on your behalf, you can sign a form that makes the person your official “authorized representative.” Learn how.