03/18/2020

Priority Health Update

New process for submitting post-claim appeals and medical records effective Mar. 19, 2020

Starting Mar. 19, 2020, we’re making a change to how you submit appeals and medical records that are related to an existing claim (i.e. post-claim), allowing us to return decisions faster. Instead of submitting these appeals and medical through your Secure Mailbox, you’ll now submit them in the Claims tool, following a few easy steps.

The process for submitting authorization appeals or medical records that are not related to a claim has not changed. Continue to submit these appeals using your Secure Mailbox.

We've created a new "Submit an appeal" button in the Provider Center to direct you to the correct tool.

Because the process for submitting an appeal differs depending on if the appeal has a related claim, we’ve created a new button in the Provider Center, titled Submit an appeal, to direct you to the appropriate tool.

When you click on this button you’ll be directed to a page where you can select the type of appeal you’re submitting. Select Pre-claim appeals for appeals not related to an existing claim. You’ll be directed to Secure Mailbox. Select Post-claim appeals for appeals that are related to an existing claim. You’ll be directed to the Claims tool.

How to submit a post-claim appeal or medical records within the Claims tool:

1. Once inside the Claims tool, use the Claim Number Search tab to search for and select the related claim.
2. In the Remittance Advice that opens, click Contact us
3. In the What is your message about? drop down menu, select Appeals or Submit medical records
4. If submitting an appeal, choose whether this is your first or second appeal attempt (Level I or Level II)
5. Specify the claim line in question, then enter your name, phone number and a message explaining the appeal
6. Upload attachments (e.g. appeals form, supporting documentation)
7. Click Send

You’ll receive a confirmation screen and email from Provider Services with an inquiry number and additional information about your request.

For more information about our appeals process, including the difference between Level I and Level II appeals, see our Provider Manual.

Get smarter access to the information you need

We value our provider partnerships and want to make sure working with us is easy and convenient. 

Our Provider Manual gives you access to need-to-know information, like:

• Care management services- Learn how to refer patients for our care management services.
• Drugs - Access our approved drug list, pharmacy management procedures and prescription drug updates.
• Provider contacts - Find contact information for our departments, including how to connect with our utilization management staff.
• Educational webinars - Sign up for our Virtual Office Advisories.
• Provider responsibilities - View access and availability, and medical records standards.
• UM program - Find utilization management criteria for medical, pharmacy and behavioral health, and our affirmative statement about incentives.
• Advance care planning - Learn how to inform your patients of their right to formulate advance directives.
• Rights and responsibilities - Review member rights and responsibilities statements.
• Disease management - Learn how to use our disease management services.

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Special thanks to our 

Priority Health Managed Care Committee Member

Flora Varga

from

Cancer, Hematology & Rheumatology Centers of West Michigan