FEHB plan member appeals process
This process applies to members of Priority Health Federal Employee Health Benefits (FEHB) plans.
If you've called our Customer Service representatives and you're still not satisfied with service you received from Priority Health or one of our providers, or with our decision to cover or not cover a medical procedure or service, you or someone acting on your behalf can send us a formal request to reconsider our first decision. This formal request for us to reconsider your complaint is called an "appeal".
When to file an appeal with Priority Health
You must file a formal appeal within 6 months of when Priority Health denied your first request.
Ask for documents
To help you prepare your appeal, you may review and copy, free of charge, all relevant materials and plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To ask to review and get copies of our documents, call 800.446.5674 or write to:
Customer Service Department
MS 1145, Priority Health
Grand Rapids, MI 49501-0269
How long the appeal process takes
If you have not yet received the services: We have 72 hours after you make your request to:
- Let you know our decision
- Or, let you know that we need more information before we can make a decision.
If you have already received the services: We have 30 days from the date we receive your appeal request to:
- Pay the claim
- Or, write to you explaining that we still deny the claim
- Or, ask you or your provider for more information.
If we request more information: You or your doctor or other health care provider must send the information we ask for within 60 days of our request. We will then make our decision within 30 days of when we receive your additional information.
Level 1: File an appeal
You can file an appeal in one of several ways. Whichever way you choose, we suggest you look at the FEHB appeal process instructions PDF first. Then you can:
- Fill out our online FEHB Appeal Form to make your appeal.
- OR, fill out a paper form. You can print the form now or call Customer Service at 800.446.5674 and ask us to mail one to you. It includes instructions on how to mail or fax back to us.
- OR, type up your request and documentation without using the form, and fax it to us at 616.975.8894.
- OR, call us at the number on the back of your membership card and we'll take down your information for you and help you get started.
Our review process
- A group of Priority Health employees who are experienced in coverage issues informally reviews your request.
- If they can't resolve it to your satisfaction, they send your appeal to the Priority Health Grievance Committee.
- The Grievance Committee includes Priority Health employees and a medical doctor, none of whom were involved in the initial decision we made or work directly for someone who made that initial decision. They make a decision about your appeal. The decision may be all or partly in your favor, or all against you.
- The Committee sends you a letter summarizing its findings and decision within 5 days after the committee meeting. We also call you.
Level 2: Requesting a review from OPM
If you are not satisfied with the resolution of your appeal, above, you may ask the United States Office of Personnel Management (OPM) to review it. You must write to OPM within:
- 90 days after the date of our letter upholding our initial decision; or
- 120 days after you first wrote to us, if we did not answer that request in some way within 30 days; or
- 120 days after we asked for additional information.
Check our FEHB Appeals Process document for what information OPM needs and where to send your request.
Level 3: Filing a civil lawsuit
If you don't agree with the OPM decision, your only option is to file a lawsuit. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs or supplies. This is the only deadline that may not be extended. You may not file a lawsuit until you have completed the disputed claims process above.