General Appeals Request Form

Grievance form/MyPriority appeal form

If you need help filling out the form, contact Customer Service. The information you submit is private and will only be used for your grievance or appeal review.

Priority Health is committed to maintaining the confidentiality of the information that you send to us. This form is not using regular email. We use advanced data encryption to send your information to Priority Health securely. Read more about Priority Health's commitment to the privacy of your personal info

Personal information

1. First name *This question is required.

2. Last name *This question is required.

3. Contract number *This question is required.

4. Person completing form If other than member

5. Member street address *This question is required.

6. City *This question is required.

7. State *This question is required.

8. ZIP *This question is required. This question requires a valid number format.

9. Home phone number Use this format: 6165551212 This question requires a valid number format.

10. Work phone This question requires a valid number format.

Grievance/appeal details

11. Is this concerning a claim? *This question is required.

12. What was the date of service? This question requires a valid date format of MM/DD/YYYY.

calendar

13. Was service authorized? By whom?

14. Under what section of your coverage documents do you believe this service would be covered?

15. Outline the facts pertaining to this grievance/appeal. (dates, type of service, etc.)

16. Outline the action you are requesting and describe the rationale which supports your position.

17. Let us know if you will be sending in any additional information for the Committee to review.

ACKNOWLEDGMENT

By submitting this appeal, I understand that Priority Health will complete a thorough investigation of my appeal for review by the Appeal Committee. 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 and infections, and other conditions, ailments, sicknesses and diseases, including human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS).

*If a person other than the member is completing this form, we will need a HIPAA authorization from the member.