Level I appeals process, commercial plans

Definition of a Level I appeal

A Level I appeal is a formal request by a provider for Priority Health to re-examine its initial adverse determination of a claim or authorization after the initial claim review process is completed.

An appeal must include further documentation to support services rendered or payment expected.

Level I appeal process

Appeals will not be considered until the initial claim review process is completed. Go to the claim review process.

Deadline: Within one year of the date of service

Steps:

  1. The servicing provider completes a Level I appeal form. We will not accept appeals from providers that did not perform the service.
  2. Fax it to the number on the form or use your use your secure Mailbox to send us the form and supporting notes or documents related to the appeal. Do not include corrected claims or new claims to be processed.
  3. Include supporting documentation for your request. 
  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. We will inform you of the outcome of the review either by remittance advice or by adverse determination letter within 5 business days of the decision.
  6. If Priority Health upholds the denial, you will be informed of the process you will need to file a Level II appeal.