Level I appeals, commercial plan rules

Definition of a Level I appeal

A Level I appeal is a formal request by a provider for Priority Health to re-examine its initial adverse determination of a claim or authorization after the initial claim review process is completed. If you haven't completed an initial claim review, we won't process your appeal.

An appeal must include additional documentation to support services rendered or payment expected.

As of 11/01/2021, providers only have one appeal right with Priority Health. Any future claim corrections performed within the remaining 12 months won't result in additional appeal rights.

Level I appeal process

Deadline

  • Pre-claim: Within 30 days of the denial
  • Post-claim: Within 180 days of the remittance advice

How to submit a Level I appeal

Visit the Appeals page in prism. We won't accept appeals from providers that did not perform the service.

For non-participating provider and pre-claim appeals, the servicing provider must either complete the Level I appeal form or submit an appeal letter.

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

Use this option when you want to appeal your denied authorization.

  1. Log into your prism account
  2. Click New Pre-Claim Appeal
  3. Choose the appropriate Request Type:

    Appeal, pre-claim inpatient emergent: utilize when acute inpatient authorization (admitted through ED or conversion from outpatient surgery) has been denied and no claim has been submitted.

    Appeal, pre-claim inpatient elective: utilize when to Elective Inpatient authorizations that have been denied preservice and no claim has been submitted. **Do not submit acute or emergent inpatient admissions here.

    Appeal, pre-claim outpatient: utilize when outpatient medical authorizations that have been denied preservice and no claim has been submitted.

  4. Complete the required fields and attach your supporting documentation
  5. Your inquiry will appear within the Appeals list page upon submission

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

If you haven't completed an initial claim review, we don't process your appeal.

  1. Log into your prism account
  2. Click New Claim Appeal, then click on the claim number you wish to appeal
  3. On the Claims Detail screen, click Contact us
  4. In the drop-down menu, select Appeals
  5. Enter your name, phone number, message and attachments
  6. Include supporting documentation for your request, related to the appeal. Don't include corrected claims or new claims to be processed
  7. Your inquiry will appear within the Appeals list page upon submission

After the Level I appeal is submitted

Priority Health specialists will review the contractual, benefit claims and medical record information.

We'll inform you of the outcome of the review either by remittance advice or by adverse determination letter within 30 calendar days of the submission. If we uphold a pre-claim denial, you'll be informed of the process for filing a Level II appeal.

What items are necessary for a medical appeal?

  • Level I appeal form (for pre-claim appeals or non-participating providers, only)
  • Provider appeal letter
  • Supporting clinical documentation including: admission summary, physician, documentation, medical testing and a discharge summary, if applicable
  • Priority Health denial letter (recommended)