Level II appeals, commercial plan rules

Level II appeals are available for pre-claim only. If we deny your Level I appeal, you can follow this process to file a Level II appeal. 

Deadline: Within one year of the date of service

How to submit a Level II appeal

Visit the Appeals page in prism, where you'll be directed to the correct tool for submitting the appeal, depending on the type of appeal you're submitting. We won't accept appeals from providers who didn't perform the service.

The servicing provider must complete a Level II appeal form or submit an appeal letter. 

Use your Secure Mailbox to submit the Level II appeal form or an appeal letter with supporting notes or documents related to the appeal. In the What is your message about field, select Appeal, pre-claimBe sure to include new documentation showing why we should reconsider our initial denial of your request. 

After the Level II appeal is submitted

Priority Health staff and/or third-party consultants will make a decision on your Level II appeal within 30 days of receipt. 

We'll inform you of the outcome of the review either by remittance advice or by adverse determination letter within five business days of the decision. 

What items are necessary for a medical appeal?

  • Level II appeal form (for pre-claim appeals only) 
  • Appeal level letter (outlining what you are appealing and why we should reconsider our decision) 
  • New pertinent supporting documentation to support your appeal