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 one year of the date of service
How to submit a Level I appeal
Visit the Submit an appeal page in the Provider Center, where you'll be directed to the correct tool, depending on the type of appeal you're submitting. We will not 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, select Appeal, pre-claim.
Post-claim appeals (appeals related to an existing claim)
Use the Claims tool to submit your appeal.
- Search for the related claim by claim number
- From the remittance advice (claim 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. Do not 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 five business days of the decision. If we uphold the 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)