MyPriority plan appeal process
If you have called our MyPriority® Customer Service representatives and you disagree with the explanation they give you, 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 two years from the date you learn of a problem to file an appeal with us.
You can file an appeal to ask us to change a decision about any of the following:
- What your MyPriority plan covers (such as coverage for experimental or investigational or not medically necessary or appropriate)
- Eligibility or cancellation of your coverage
- Payment of claims (in whole or in part)
- How we've handled payment or coordination of health care services
- Contracts with our providers
- Availability of care or providers
- A decision not in your favor. This may include services that have been reviewed by Priority Health and denied, reduced or terminated. It also may include a slow response to a request for a decision from us.
There are two steps to the Priority Health appeal process. If your issue is resolved at Step 1, you don't have to do anything else. If you complete Step 1 and are still not happy with our decision, you may choose to go to Step 2.
Step 1: File an appeal with Priority Health
You must file an appeal within two years of our deciding against your request (an "adverse determination"), or within two years of the date you learn we made the adverse determination, whichever is later.
You can file an appeal in one of several ways. Whichever way you choose, we suggest you look at the instructions in the MyPriority appeal process PDF first. Then you can:
Submit your appeal online by filling out our online appeal form.MyPriority appeal form
OR, fill out a paper form. You can print the form and instructions now or call Customer Service at the number listed on the back of your membership card and ask us to mail one to you. Attach any additional documentation you would like to include in your case review on the form. Print the MyPriority appeal form PDF.
OR, type up your request and fax it, along with any additional documentation you would like to include in your case review, to us at 616.975.8894.
OR, call us at the number on the back of your membership card and request a verbal appeal. We'll take down your information and help you get started.
Appeal process timeline
If you have not yet received the services: We must make a final determination within 30 calendar days after we receive your appeal. The 30-day count does not include any days you or your representative may delay the process.
If you have already received the services: We must make a final determination within 35 calendar days after we receive your appeal. The 35-day count does not include any days you or your representative may delay the process.
Step 2: Request a state external review
If you are not satisfied with the resolution of your problem or complaint after completing the Priority Health Appeal Process, you have 120 days after receiving your Step 1 decision to request a review by the Michigan Department of Insurance and Financial Services (DIFS).
Check the instructions in the MyPriority appeal process PDF for how to file a request with the state.
You'll find more details in the coverage documents you received when you enrolled in your MyPriority plan. These documents may include an Agreement or an Insurance Policy. Call Customer Service with questions.