How to file an appeal with Priority Health

After you have formally asked for an exception to what drugs and services we cover under your Priority Health Medicare plan and we have made a decision not to cover what you ask for, you can ask us to reconsider your request. This is called an appeal. See below for how to file an appeal.

• Go back to instructions for requesting an exception.

A complaint about the service you get from Priority Health, its doctors, pharmacies, hospitals, or other health care providers, is called a grievance.

• Learn about how to file a grievance about service.

Making an appeal

If you ask that we pay for a certain drug or service for you, but we turned down your request, you can ask us again. This is called "appealing" our decision.

• There are five levels of the appeals process.
• At each level, your request is considered again and a new decision made.
• The decision may be all or partly in your favor, or all against you.
• If you are unhappy with the decision, you may be able to ask for the next level of appeal.

Follow these steps to file an appeal:

1. Decide if you want someone else, like a spouse, child, or friend, to make an appeal for you. This person will be your "authorized representative."
   Go to the instructions for naming an authorized representative.
2. You or your authorized representative may write us a letter telling us that you want to appeal our decision. Include your name, member ID number, and a daytime phone number where we can reach you or your authorized representative.
3. State the reasons why you think we should reconsider our decision. Tell us where in your "Evidence of Coverage" document (see links below) you think it says we will pay for the service or drug.
4. Mail your appeal letter (and your form authorizing your representative to act for you, if any) to:

Priority Health Appeal Coordinator
1231 East Beltline NE
MS 1145
Grand Rapids, MI 49525

You can also deliver it in person, or fax it to us at 616 942-0886, or call Customer Service for help.

5. To learn more about the appeals process or to check on the status of your appeal, call Customer Service and ask to speak to an appeals coordinator. See your "Evidence of Coverage" booklet (links below) for ways to ask for a "fast decision" or "72-hour decision."

For complete details, see your Evidence of Coverage booklet.

The information above is a summary of the full explanation and instructions for making appeals in your plan's Evidence of Coverage booklet. For more complete instructions, use the links below to open your plan's booklet.

• Go to Chapter 9 of the Evidence of Coverage for PriorityMedicare Value plan, (1.7MB PDF) 
• Go to Chapter 9 of the Evidence of Coverage for PriorityMedicare plan, (1.7MB PDF)  
• Go to Chapter 9 of the Evidence of Coverage for PriorityMedicare Plus plan, (1.7MB PDF) 
• Go to Chapter 9 of the Evidence of Coverage for PriorityMedicare Choice plan, (1.7MB PDF)
  
• Go to Chapter 7 of the Evidence of Coverage for PriorityMedicare Rx plan, (980KB PDF) 

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