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.
An appeal must include further documentation to support services rendered or payment expected.
Level I appeal process
Appeals will not be considered until the initial claim review process is completed. Go to the claim review process.
Deadline: Within one year of the date of service
- The servicing provider completes a Level I appeal form. We will not accept appeals from providers that did not perform the service.
- Use your secure Mailbox to send us the form and supporting notes or documents related to the appeal. Do not include corrected claims or new claims to be processed.
- Include supporting documentation for your request.
- Priority Health specialists will research and compile the contractual, benefit, claims and medical record information. The collected information will be used to construct a chronology of events with all pertinent dates.
- We will inform you of the outcome of the review either by remittance advice or by adverse determination letter within 5 business days of the decision.
- If Priority Health upholds the denial, you will be informed of the process you will need to file a Level II appeal.
What items are necessary for a medical appeal?
- Priority Health appeal form
- Provider appeal letter
- Supporting clinical documentation including: admission summary, history and physical documentation and a discharge summary
- Priority Health denial letter (recommended)