What makes a good appeal? Tips from our Reimbursement team

What’s an appeal?

When you make an appeal, you’re asking us to change our reconsideration decision, our utilization review decision or our initial claim decision based on medical necessity or experimental / investigational coverage criteria. We only offer one level of post-claim appeals.

You can submit an appeal to dispute:

  • Payment issues
  • Clinical claim edits
  • Denial of a claim

You can't submit an appeal to dispute:

  • Billing errors (we close these and send a note to the provider with information on the error)

What makes a good appeal?

Keep this information in mind when submitting your appeals:

  1. Start with the basics – Who are you appealing for? What are you appealing? What do you want us to review?
  2. Be specific – Include information on what was denied and the cited reason for the denial (i.e.: contract, fee schedules and any documentation to support your appeal)
  3. Be thorough – Be sure to include plenty of detail. Complete and accurate information is key. Consider whether you have charges, office notes, Radiology and lab / pathology reports, operative notes, etc. to include

When will you hear back?

We typically respond to provider appeals in writing within 30 calendar days of receipt of the written appeal. However, the time frame may be extended depending on the nature of the appeal.

Reviews for multiple claims

We’re unable to accept an email for claims review for multiple members due to the Health Insurance Portability Accountability Act (HIPPA). Please use the following guidelines when initiating a claim review:

  • If it’s an issue affecting more than 10 members’ claims, use the “Claim status” tool on priorityhealth.com to send us one example. Be sure to indicate what the issue is and that it’s happening to multiple members’ claims. We’ll investigate and contact you if we need more examples.
  • If it’s the same issue affecting less than 10 members’ claims or it’s different issues for each member, please use the “Claim status” tool on priorityhealth.com for each individual claim you’re requesting we review, along with an explanation of the issue.

Visit our Reviews & Appeals webpage for more