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).
How to submit an appeal
- 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
Grand Rapids, MI 49525
Fax Number 616.975.8827
- 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.
- 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.
- If the IRE renders a favorable decision for you, Priority Health Medicare must effectuate and comply with the IRE's decision.