Member Appeals Form

Member information

1. First name *This question is required.

2. Last name *This question is required.

3. M.I. *This question is required. Middle Initial

4. Date of birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

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5. Priority Health ID number *This question is required. Please provide the number on your Priority Health membership card (not the primary subscribers card).

Please include all numbers and dashes and confirm accuracy.

photo of member ID card

6. Street address *This question is required.

7. Unit/apt./lot no.

8. City *This question is required.

10. Zip Code *This question is required.

11. Email Providing an e-mail address will allow us to send a confirmation and contact you for follow up. The provided e-mail will not be used for other outreach. This question requires a valid email address.

12. Are you out of state? *This question is required.

13. Phone *This question is required.

14. Are you an authorized representative completing this form *This question is required.

Authorized representative details

Priority Health must have an Appointment of Representative (AOR) form or other legal documentation (Durable Power of Attorney, Executor of Estate, etc.) when a request for a grievance and/or appeal is submitted by someone other than the member. If this form or other legal documentation is not on file, we are unable to continue with the appeal or grievance. Member must provide a written authorization.

For members under the age of 18, a parent or legal guardian is automatically appointed as the authorized representative.
For matters involving substance abuse or behavioral health treatment, a parent or legal guardian is automatically appointed as an authorized representative if the member is under the age of 14.

You can download a form to appoint a new representative to complete and e-mail it to phmemberappeals@priorityhealth.com
Medicaid Appointment of Representative Form
Employer Group/MyPriority Appointment of Representative Form

If you already have relevant Legal Documentation (i.e. Letter of Authority for Personal Representative, Power of Attorney for Healthcare, Trust Agreement, Probate Court Order, etc) please e-mail them to phmemberappeals@priorityhealth.com.

15. First name *This question is required.

15. Last name *This question is required.

15. M.I. Middle Initial

15. What is your relationship to the member? *This question is required.(choose one)

Please enter an 'other' value for this selection. * This question is required.

15. If ‘Healthcare provider’, provide your National Provider Identifier (NPI): *This question is required.

15. Street address *This question is required.

15. Unit/apt./lot no.

15. City *This question is required.

15. Zip Code *This question is required.

15. Email This question requires a valid email address.

15. Phone *This question is required.

15. Signature of member, parent (if under the age of 18) or legal guardian *This question is required.

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Signature of

15. Date of Signature *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Decision information

15. Where do you want the decision to be sent? *This question is required.(mark all that apply)

Member
Authorized representative
Other individual/place

Other individual or place details

16. Name *This question is required.

16. Street address *This question is required.

16. Unit/apt./lot no.

16. City *This question is required.

16. Zip Code *This question is required.

16. Email This question requires a valid email address.

16. Phone *This question is required.

Appeal type

16. What is the type of issue you are appealing? *This question is required.(choose one)

Please enter an 'other' value for this selection. * This question is required.

Appeal details for Preservice denial

17. Provider name *This question is required.

17. Authorization number *This question is required.

17. Location name *This question is required.

17. Date of Service(s) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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17. Types of Service(s) *This question is required.

17. Have you already received the service(s)? *This question is required.

17. What is the total charged amount? *This question is required.

17. What is the claim number? *This question is required. You can add multiple claim numbers

17. Do you need continuation of services? *This question is required.To request continuation of services, you must submit this form within 10 days of the initial denial notification.

17. Would standard review time put your life in danger or delay treatment for severe pain? *This question is required.A healthcare provider will confirm this.

17. If Yes, explain *This question is required.

Appeal details

17. Describe the reason you are requesting an appeal with a brief explanation of the problem and the resolution you are seeking. If applicable, please include details on the service you have requested or received, such as dates, provider names, claim numbers, authorization numbers, etc. *This question is required.

Acknowledgement

18. By submitting this appeal, I understand Priority health will complete an investigation on my appeal. I understand that this may involve contacting appropriate providers to gather relevant medical records including photos, claims information relating to diagnosis, prognosis and treatment for physical and mental illness, mental health, substance abuse, communicable diseases, serious communicable diseases and infections and other conditions, ailments, sicknesses and diseases, including human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS). *This question is required.

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Signature of

19. Date of Signature *This question is required. This question requires a valid date format of MM/DD/YYYY.

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If you have information, records or additional documentation to submit with your appeal, you can email phmemberappeals@priorityhealth.com. The appeals team will respond within 48 hours.