Appealing a pre-service organization determination (PSOD)

 

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.

Appealing a denied "pre-service decision"

To ask that Priority Health Medicare reconsider a pre-service decision, follow the "Appealing on behalf of a member" process. 

Standard pre-service organization determination (PSOD) appeal requests:

Any provider may file a pre-service organization determination (PSOD) on behalf of a member. Appealing a denied PSOD requires the provider to affirm:

  • He or she is filing a PSOD appeal on behalf of the member, and
  • The member is aware and has approved the provider acting on his/her behalf.

Expedited redetermination requests: Expedited appeal requests are for situations where applying the standard procedure could seriously jeopardize the member's life, health or ability to regain maximum function. See Section 50, Part C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance (updated February 2019).

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.

Non-contracted providers may file a request for appeal for purposes of obtaining payment. This requires you to submit a waiver of liability form with Priority Health or your request for reconsideration will not be accepted. The waiver of liability formally waives any right to payment from the enrollee for a service in the event our decision is not favorable to the non-contracted provider.

Post service appeals cannot be expedited.