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:
- 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.
- Give us the reasons why you think we should reconsider our decision. Use one of these ways:
Medical appeals Requests for drug redeterminiations - 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)
Print this form, complete it and fax or mail it to us:
Request for Redetermination of Medicare Prescription Drug Denial (PDF)
- Submit your form online, or mail your letter or form (and your authorization for your representative to act for you, if any) to:
Priority Health Medicare Appeal Coordinator
1231 East Beltline NE
Grand Rapids, MI 49525
You can also deliver it in person, or call Customer Service for help.
- 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., 7 days a week, at 888.389.6648. TTY users should call 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.
- 2022 PriorityMedicare EOC
- 2022 PriorityMedicare Compass EOC
- 2022 PriorityMedicare D-SNP EOC
- 2022 PriorityMedicare Edge EOC
- 2022 PriorityMedicare Ideal EOC
- 2022 PriorityMedicare Key EOC (Regions 3, 4)
- 2022 PriorityMedicare Key EOC (Regions 1, 2, 5)
- 2022 PriorityMedicare Merit EOC
- 2022 PriorityMedicare Select EOC
- 2022 PriorityMedicare Value EOC
- 2022 PriorityMedicare Vital EOC
- 2021 PriorityMedicare EOC
- 2021 PriorityMedicare Compass EOC
- 2021 PriorityMedicare D-SNP EOC
- 2021 PriorityMedicare Edge EOC
- 2021 PriorityMedicare Ideal EOC
- 2021 PriorityMedicare Key EOC (Regions 3, 4)
- 2021 PriorityMedicare Key EOC (Regions 1, 2, 5)
- 2021 PriorityMedicare Merit EOC
- 2021 PriorityMedicare Select EOC
- 2021 PriorityMedicare Value EOC
- 2021 PriorityMedicare Vital EOC