Appeal a denial of payment for services to a Medicare member

The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage Organizations (MAOs), including Priority Health Medicare, to have a provider appeal process that includes:

  • Asking for a review of claims payment
  • Making an appeal on behalf of a member
Plans included:

This CMS process applies to Medicare-covered medical services and supplies for patients covered by: 

  • Priority Health Medicare Advantage plans
  • Employer group Medicare plans covering their retirees
Definitions:
  • Organization determination: A decision made by a MAO to approve, deny, furnish, arrange for, or provide payment for health care services.
  • Organization reconsideration: The first step in the member appeal process after an organization determination denies payment as the patient's responsibility.

Standard post-service appeal requests

Contracted providers may file an appeal on behalf of the member ONLY if they are the member's appointed representative, that is, the member has completed an Appointment of Representative (CMS-1696) form (also available in Spanish) designating the contracted provider as his/her appointed representative. Otherwise, contracted providers do NOT have appeal rights under Medicare rules. Contracted providers should follow the Medicare member appeal process. Post service appeals cannot be expedited.

How to submit an appeal

  1. Submit your appeal within 60 calendar days from the date of the explanation of benefits. Submit by mail or fax:

    Priority Health Medicare Appeals
    1231 E. Beltline Ave NE
    MS 1150
    Grand Rapids, MI  49525
    Fax Number 616.975.8827

  2.  For standard appeals: Priority Health Medicare will review your appeal and notify you in writing of our decision within 60 calendar days of receipt of the appeal
  3. If Priority Health Medicare renders a partial or fully adverse decision, we automatically send your appeal to MAXIMUS Federal Services. This is Medicare’s Independent. Review Entity (IRE).  You will receive a correspondence by mail regarding their decision.
  4. If the IRE renders a favorable decision for you, Priority Health Medicare must effectuate and comply with the IRE's decision.
  5. Include supporting documentation for your request, related to the appeal. Do not included corrected claims or new claims to be processed.