Medicare post-claim appeals

The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage Organizations (MAOs), including 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

Step 1: Informal claim review

You must wait 45 days after submitting a claim to request a review.

You must complete the Informal Claim Review process and receive a decision before submitting an appeal. (The informal claim review process for Medicare is the same as for commercial plans.)

Step 2: Appeal

Definition of an appeal

An 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. If you haven't completed an initial claim review, we won't process your appeal.

An appeal must include additional documentation to support services rendered or payment expected. We won't accept appeals from providers that did not perform the service.

Providers only have one post-claim appeal right with Priority Health. Any future claim corrections performed within the remaining 12 months won't result in additional appeal rights.

Deadline for post-claim appeals

You must submit your appeal within 180 days of the remittance advice

What will you need?

When you submit your appeal, you must upload additional documentation to support the services rendered or payment expected. Here’s our tips for choosing what documents to upload:

Make sure the documentation supports the appeal
Send final documents only, not preliminary results
Only send paperwork related to the specific date of service in question
Send only what’s relevant – we don’t need discharge paperwork, service orders etc. Don’t include corrected claims or new claims to be processed.

In addition to supporting documentation, you’ll also need to upload:

Provider appeal letter
Supporting clinical documentation including: admission summary, physician, documentation, medical testing and a discharge summary, if applicable
Priority Health denial letter (recommended)

How to submit a post-claim appeal

Make sure you're completed the informal claim review process first.

Process for in-network providers

Log into your prism account.
Click New Claim Appeal, then click on the claim number you wish to appeal.
On the Claims Detail screen, click Contact us about this claim.
In the drop-down menu, select Appeals.
Enter your name, phone number, message – including the disputed code – and attachments. Make sure to include supporting documentation (see below) for your request as described above.

Supporting documentation can include contract language, CMS information, proof of timely filing, etc. We won't accept the following as supporting documentation: remittance advice, a copy of a claim, a system print out – we'll close the inquiry. Additionally, we don't accept medical records for claim appeals unless specifically requested.

Also include the following, as appropriate:

Specifics on what was denied and the cited reason for denial
Fee schedules
Any justification that supports your appeal
Click Submit. Your inquiry will appear within the Appeals list page upon submission

Process for out-of-network providers

See the following pages for instructions:

After submitting your appeal

Our specialists will review the contractual, benefit claims and medical record information.

We'll inform you of the outcome by entering a comment into prism, which triggers an email to notify you. Review either by remittance advice or by adverse determination letter within 30 calendar days of the submission.