Level II appeals, commercial plan rules

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 Submit an appeal page in the Provider Center, where you'll be directed to the correct tool for submitting the appeal, depending on the type of appeal you're submitting. We will not accept appeals from providers who did not perform the service.

For non-participating providers and pre-claim appeals, the servicing provider must complete a Level II appeal form.

Pre-claim appeals (appeals not related to an existing claim)

Use your Secure Mailbox to submit the Level II appeal form and 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.

Post-claim appeals (appeals related to an existing claim)

Use the Claims tool to submit your appeal. 

  1. Search for the related claim by claim number
  2. From the remittance advice (claim detail) screen, click Contact us
  3. In the drop down menu, select Appeals, Appeal Level and the claim line you're appealing. If a specific line does not apply, select Entire claim
  4. Enter your name, phone number fax number and attachments
  5. Include supporting documentation for your request, related to the appeal. Do not include corrected claims or new claims to be processed

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 or non-participating providers, only) 
  • Appeal level letter (outlining what you are appealing and why we should reconsider our decision) 
  • New pertinent supporting documentation to support your appeal