Priority Health Claim Denied? How to Appeal in Michigan

Priority Health is one of Michigan's largest health insurers, headquartered in Grand Rapids and closely affiliated with Corewell Health (formerly Spectrum Health), one of the largest hospital and physician organizations in Michigan. Priority Health serves more than 1.3 million members statewide with commercial employer-sponsored plans, individual and family plans, Medicare Advantage, and Medicaid managed care products. If your claim was denied, Michigan law and federal regulations give you strong rights to challenge that decision.

Understanding Priority Health

Priority Health is regulated by the Michigan Department of Insurance and Financial Services (MI DIFS), which has broad authority to investigate insurer misconduct and consumer complaints. Priority Health's close relationship with Corewell Health—which includes Butterworth Hospital, Blodgett Hospital, Helen DeVos Children's Hospital, and dozens of ambulatory care centers—gives members extensive in-network options in West Michigan and beyond.

Priority Health also operates the Priority Health Medicare (Medicare Advantage) and Medicaid (Healthy Michigan Plan) products, each with distinct appeal rights.

Common Reasons Priority Health Denies Claims

• Prior Authorization Denied: How to Appeal" class="auto-link">Prior authorization: Priority Health requires advance approval for many services, including specialist referrals, surgeries, specialty medications, imaging, inpatient admissions, and post-acute care.
• Medical necessity: Priority Health applies clinical criteria to determine whether a service is medically necessary. Medical necessity denials are the most common type and are frequently successfully appealed.
• Out-of-network care: Priority Health HMO and exclusive provider organization (EPO) plans require in-network care except in emergencies. Out-of-network claims may be fully denied.
• Formulary restrictions: Specialty drugs, non-preferred medications, and certain therapies may require step therapy or prior authorization.
• Step therapy failures: If Priority Health requires you to try a less expensive drug first and you have not documented that attempt, specialty drug approvals may be denied.

Your Appeal Rights in Michigan

Michigan law and federal regulations provide Priority Health members with the following appeal rights:

Internal Appeal: File your internal appeal within 180 days of the denial. Priority Health must respond within 30 days for standard appeals and 72 hours for urgent/expedited appeals.

External Independent Review: Complete Guide" class="auto-link">External Review: After exhausting your internal appeal, Michigan law gives you the right to an independent external review by a certified IROs) Explained" class="auto-link">Independent Review Organization (IRO). The IRO's decision is binding on Priority Health. Apply for external review within 60 days of the final internal denial.

MI DIFS Complaint: File a complaint with the Michigan Department of Insurance and Financial Services at any point. The MI DIFS Consumer Service Division investigates insurance complaints and can require Priority Health to justify its decisions.

Michigan Department of Insurance and Financial Services Contact:

• Consumer Services: 877-999-6442
• Website: michigan.gov/difs
• Online complaint portal: michigan.gov/difs/consumers/consumer-complaints

Medicare Advantage Members

Priority Health Medicare Advantage members have separate federal appeal rights. Standard organization determinations must be decided within 72 hours. After internal denial, escalate to Maximus Federal Services (the Medicare independent review entity) and, if needed, the Office of Medicare Hearings and Appeals (OMHA).

Medicaid (Healthy Michigan Plan) Members

Priority Health administers Healthy Michigan Plan (Medicaid expansion) and other Medicaid products. Medicaid members can request:

• An internal appeal with Priority Health within 60 days
• A state fair hearing through the Michigan Office of Administrative Hearings and Rules at 800-648-3397

How to File a Priority Health Appeal

1. Review your denial notice: Priority Health must provide written notice stating the specific denial reason, the clinical criteria applied, and your appeal rights.

2. Contact Priority Health Member Services: Call 800-942-0954 or the number on your insurance card. Ask for the appeals and grievances department.

3. Submit your written appeal: Mail to Priority Health, Grievances and Appeals, P.O. Box 232, Grand Rapids, MI 49501-0232. Include your member ID, claim number, denial notice, physician letter of medical necessity, and supporting clinical documentation.

4. Involve your treating physician: A detailed letter of medical necessity from your doctor that specifically addresses Priority Health's denial criteria is your most effective tool. Ask your physician to reference applicable clinical practice guidelines.

5. Request a peer-to-peer review: Your physician can request a clinical peer-to-peer discussion with Priority Health's medical director. For Corewell Health physicians who treat Priority Health members, this relationship may facilitate faster resolution.

6. File a complaint with MI DIFS: If Priority Health is unresponsive or you believe the denial is improper, contact the Michigan DIFS.

Corewell Health Network Considerations

Priority Health's affiliation with Corewell Health means that Corewell-affiliated providers are generally in-network. However, denials can still occur for:

• Prior authorization requirements even within the Corewell system
• Services at non-Corewell hospitals when you need a specialized service not available at Corewell
• Post-acute care transitions from Corewell hospitals to rehabilitation or skilled nursing facilities
• Specialist care from physicians who are employed by Corewell but not contracted with Priority Health for specific plan products

If your denial involves a Corewell Health provider, ask the Corewell billing or care management team to initiate a peer-to-peer review directly with Priority Health's utilization management staff.

Tips for Priority Health Appeals

• Step therapy overrides: Michigan does not have a general step therapy override law, but Priority Health's plan documents may allow exceptions when your physician documents that the required first-step drug is contraindicated or has already failed.
• Mental health parity: Michigan law and federal MHPAEA require Priority Health to cover mental and behavioral health services at parity with medical/surgical benefits. Behavioral health denials that appear inconsistent with how Priority Health handles similar medical claims are worth challenging on parity grounds.

Fight Back With ClaimBack

Priority Health denials in Michigan are frequently reversed with a well-prepared appeal. ClaimBack helps you draft a targeted, evidence-backed appeal letter and navigate Michigan's consumer protection framework.

Start your free Priority Health appeal at ClaimBack

Related Reading

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Common Reasons Insurance Claims Are Denied