Medicare claim reviews and appeals

The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage Organizations (MAOs), which includes Priority Health Medicare, to have a provider appeal process that includes:

  • Asking for a review of claims payment
  • Making an appeal on behalf of a member
Plans included:

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, below.

Appealing a denied claim ("Medicare dispute process")

To ask that Priority Health Medicare reconsider its organization determination denying payment for a service that has already been performed, follow this dispute process.

Exceptions: Claims denied as patient responsibility may be reconsidered under the member appeal process: See "Appealing on behalf of a member," below.

Deadline: Requests for review through the contract dispute process must be made within one year of the date of service.

Steps:

  1. Complete a Level I appeal form and fax it to the address on the form.
  2. Include supporting documentation for us to review your request.
  3. Mail the form and supporting notes or documents to the Medicare address on the form.
  4. Priority Health specialists will research and compile the contractual, benefit, claims and medical record information. The collected information will be used to construct a chronology of events with all pertinent dates.
  5. If you are appealing a procedure that has been labeled "not medically necessary," your appeal will be forwarded to our Medical department for clinical review.
  6. If the appeal is overturned, we will send you a letter within 30 calendar days of receipt of the appeal.
  7. If Priority Health upholds the denial, you may be eligible for a second-level appeal. 

Appealing on behalf of a member

Before you request an organization reconsideration or appeal, review this information.

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 80, Chapter 13, Medicare Managed Care Manual, for more information.

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.