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
  • 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 authorization.

Appealing a denied "pre-service decision"

To ask that Priority Health Medicare reconsider a pre-service decision.

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).

Please note this reminder about an expedited appeal, or what is also referred to as “fast appeal.” Based on CMS guidelines, the expedited appeal process timeframe can be applied to cases where a physician (treating or prescribing for Part C) or other prescriber (Part D) makes a request (or supports a patient’s request) for an expedited appeal. The physician or prescriber (only Part D) should explain why applying the standard timeframe could seriously jeopardize the life or health of your patient or your patient’s ability to regain maximum function. Vague requests only labeled as “fast appeal, urgent, ASAP, etc.” without a physician statement may be evaluated by a Priority Health Medical Director and may be moved to the standard 30-day timeframe. Submitting appeals that don't meet CMS expedited criteria should be avoided.

How to submit an appeal

  1. Submit your appeal within 60 calendar days from the notice of initial determination. Send 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 30 calendar days of receipt of the appeal. For Expedited Appeals: Priority Health Medicare will review your appeal and notify you of our decision within 72 hours 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.