Priority Health Choice, Inc., appeal process (Medicaid and Healthy Michigan Plan)
This process applies to members of Priority Health Medicaid, MIChild or Healthy Michigan plans.
If you have called our Priority Health Choice, Inc., Customer Service representatives at the number on your Priority Health membership card and you disagree with the explanation they give you, then you or someone acting on your behalf can ask us to change our decision by filing an "appeal." An appeal is the action you can take if you disagree with a coverage or payment decision made by Priority Health.
You have 60 days from the date you learn of a problem to file an appeal with us.
You can request an appeal if Priority Health:
- Denies your request for a health care service, supply, item or prescription drug that you think you should be able to get
- Reduces, limits or denies coverage of a health care service, supply, item or prescription drug you already got
- Your plan stops providing or paying for all or part of a service, supply, item or prescription drug you think you still need
- Does not provide health services in a reasonable amount of time.
Appeal process overview
Filing an appeal with Priority Health Choice, Inc.
You must file an appeal request within 60 days from the date you learn of the decision you do not agree with.
You can file an appeal in one of several ways. Whichever way you choose, we suggest you look at the Priority Health Choice instructions first. Then you can:
- Fill out a paper form. You can print the form now or call Customer Service at the number listed on the back of your membership card and ask us to mail one to you. It includes instructions on how to mail or fax back to us.
- OR, type up your request and documentation without using the form, and fax it to us at 616.975.8894 or email it to PHGrievance@spectrumhealth.org.
- OR, call us at the number on the back of your membership card and we'll take down your information for you and help you get started.
What happens next
Priority Health Choice, Inc. has 30 days from the date we receive your appeal to make a decision about your request and send the decision to you in writing or in speaking with you.
Our review process
- A group of Priority Health employees who are experienced in coverage issues informally reviews your request.
- If they can't resolve it to your satisfaction, they send your appeal to the Priority Health Appeal Committee.
- The Appeal Committee includes Priority Health employees and a medical doctor, none of whom were involved in the initial decision we made or work directly for someone who made that initial decision. They make a decision about your appeal. The decision may be all or partly in your favor, or all against you.
- The Committee sends you a decision letter summarizing its findings and decision within 5 days after the committee meeting.
Request a state external review or fair hearing
If you are not satisfied with the resolution of your problem or complaint after completing the Priority Health Choice, Inc., appeal process, you may request a review by the Michigan Department of Insurance and Financial Services (DIFS) within 120 days or a Fair Hearing within 90 days from the date you receive the appeal decision from Priority Health.
Check the Priority Health Choice, Inc. Appeal Process document for information on how to file a request with the state.