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

Definition of a Level 1 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 1 appeal process

Deadline

  • 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.

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

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

  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

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

We'll inform you of the outcome by entering a comment into prism, which triggers an email to notify you. Review either by remittance advice or by adverse determination letter within 30 calendar days of the submission.

What items are necessary for a medical appeal?

  • Provider appeal letter
  • Supporting clinical documentation including: admission summary, physician, documentation, medical testing and a discharge summary, if applicable
  • Priority Health denial letter (recommended)