You have a right to an appeal if you believe you are entitled to a service or benefit that has been denied. Incomplete appeal forms may cause a delay in your appeal.
Who can complete this form?
You or an authorized representative may fill out this form. To appoint someone to represent you, you must complete, sign and submit an Appointment of Representative request form.
If you are under the age of 18, a parent or legal guardian is automatically appointed as your authorized representative.
For matters involving substance abuse or behavioral health treatment, a parent or legal guardian is automatically appointed as your authorized representative if you are under the age of 14.
What must be done to request an appeal?
To request an appeal, you must take the following action:
- Submit one appeal form for each member/appeal reason.
- If you believe you need continuation of services while your appeal is pending, you must submit this form within 10 days of the initial denial notification.
- Attach documentation relating to your appeal. This includes:
- Explanation of Benefits (EOB), receipts, medical records, statements from providers, research material, etc. Always send copies. Never send original documents.
If you need help filling out the form, contact Customer Care at the phone number on the back of your member ID card. The information you submit is private and will only be used for your appeal or appeal review.
Priority Health is committed to maintaining the confidentiality of the information that you send to us. This form is not using regular email. We use advanced data encryption to send your information to Priority Health securely. Read more about Priority Health's commitment to the privacy of your personal info
What happens next
- First, a group of Priority Health employees well-versed in coverage issues informally reviews your grievance. If they can't resolve it to your satisfaction, they will send your grievance to Priority Health's Grievance & Appeals Committee. The committee includes Priority Health employees and a medical doctor, none of whom were involved in the initial decision we made or who work directly for someone who made that initial decision.
- We send you a letter summarizing our findings and resolution. 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 file an appeal. Call Customer Service to file an appeal or learn more.