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
Deadline: Within 180 days of the first remittance advice
How to submit a Level I appeal
Visit the Appeals page in prism, where you'll be directed to the correct tool, depending on the type of appeal you're submitting. 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 your Secure Mailbox to send us the Level I appeal form or an appeal letter with supporting notes or documents related to the appeal. Do not include corrected claims or new claims to be processed. In the What is your message about field, selectthe most appropriate Appeal, pre-claim option.
Post-claim appeals (appeals related to an existing claim)
Use the Claims tool to submit your appeal.
- Log into your prism account
- Click New Claim Appeal, then click on the claim number you wish to appeal
- On the Claims Detail screen, click Contact us
- In the drop-down menu, select Appeals, Appeal Level 1 and the claim line you're appealing. Choosing the applicable line will ensure the appeal is sent to the correct department for review.
- Enter your name, phone number fax number and attachments
- Include supporting documentation for your request, related to the appeal. Don't include corrected claims or new claims to be processed
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)