Self-funded group appeals process

Note: This appeals process applies only if you’re a member of a self-funded employer group health plan. Choose the Priority Health plan you have from the menu on the right to see the process that applies to you.

If you have called our Customer Service representatives and you are still not satisfied with the answers provided to you, you can formally request that Priority Health change the response or decision provided. You or someone acting on your behalf can appeal our decision.

Level 1

Filing a formal appeal

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Ask for a review by your employer

First, read your appeals process outline:

When to file an appeal with Priority Health

For grandfathered plans

  • You must file a Level 1 appeal within 180 days of receiving an “adverse determination” of your initial request.
  • You must file a Level 2 appeal within 60 days of receiving a denial of your Level 1 appeal.

For non-grandfathered plans

  • You must file a Level 1 appeal within 180 days of receiving an “adverse determination” of your initial request.
  • You must file a Level 2 appeal within 4 months of receiving a denial of your Level 1 appeal.

How long will the process take?

If we receive your form during non-business hours, we count the day we receive it as the next business day.

For grandfathered plans

If your appeal is submitted before you receive services:

The committee will make a decision within 15 days from the date we receive your appeal request to:

  • Let you know of the committee’s decision
  • Or, let you know we need more information before we make a decision.

If your appeal is submitted after you receive services:

The committee will make a decision within 30 days from the date we receive your appeal request to:

  • Pay the claim
  • Or, let you know of the committee’s decision
  • Or, let you know we need more information before we make a decision

For non-grandfathered plans

If your appeal is submitted before you receive services:

The committee will make a decision within 30 days from the date we receive your appeal request to:

  • Let you know of the committee’s decision
  • Or, let you know that we need more information before we make a decision

If your appeal is submitted after you receive services:

The committee will make a decision within 60 days from the date we receive your appeal request to:

  • Pay the claim
  • Or, let you know of the committee’s decision
  • Or, let you know we need more information before we make a decision

Second, send us your appeal in ONE of these four ways:

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Submit your appeal online by filling out our online appeal form.

Online appeal form

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Fill out a paper form:

OR call Customer Service and ask us to mail one to you.

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Type up your request without using the form and fax it, with documentation, to us at 616.975.8894, or email it to the appeals team.

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Call the number on the back of your membership card and one of our Customer Service representatives will complete a verbal grievance/appeal on your behalf.

More details

You’ll find more details in the coverage documents you received when you enrolled in your plan. These documents may include a Certificate of Coverage. Call Customer Service with questions.