Level II appeals, Medicaid plan rules

Level II appeals are available for pre-claim only. If we deny your Level I appeal, you can follow this process to file a Level II appeal. 

Deadline: Within one year of the date of service

How to submit a Level II appeal

  1. Log into your prism account
  2. Click New Pre-Claim Appeal
  3. Choose the appropriate Request Type:

    Appeal, pre-claim inpatient emergent: utilize when acute inpatient authorization (admitted through ED or conversion from outpatient surgery) has been denied and no claim has been submitted.

    Appeal, pre-claim inpatient elective: utilize when to Elective Inpatient authorizations that have been denied preservice and no claim has been submitted. **Do not submit acute or emergent inpatient admissions here.

    Appeal, pre-claim outpatient: utilize when outpatient medical authorizations that have been denied preservice and no claim has been submitted.

  4. Complete the required fields and attach your supporting documentation.
  5. Your inquiry will appear within the General Request list page upon submission

We won't accept appeals from providers who didn't perform the service.

The servicing provider must complete a Level II appeal form or submit an appeal letter.  

After the Level II appeal is submitted

Priority Health staff and/or third-party consultants will make a decision on your Level II appeal within 30 days of receipt. 

We'll inform you of the outcome of the review either by remittance advice or by adverse determination letter within five business days of the decision. 

What items are necessary for a medical appeal?

  • Level II appeal form (for pre-claim appeals only) 
  • Appeal level letter (outlining what you are appealing and why we should reconsider our decision) 
  • New pertinent supporting documentation to support your appeal