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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyPriority Health Medicare Appeals Update | OpenPaye…
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    CurrentPriority Health MedicarePolicy 3240

    Disciplinary Action & Practitioner Appeal Policy

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    Governs disciplinary actions, reconsideration, hearing and appeal rights, final decisions, and reporting obligations for affiliated and participating practitioners, including Medicare-contracted practitioners.

    Policy Summary
    PayerPriority Health Medicare
    PolicyDisciplinary Action & Practitioner Appeal Policy
    Policy CodePolicy 3240
    Change TypeNo material change
    Effective DateSep 8, 2026
    Next Review DateN/A
    Key ActionSubmit a written hearing request within 30 days after notice of the Credentialing Committee recommendation.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    30 daysHearing request deadline
    15 daysHearing acceptance confirmation
    3–7 peersAppeal Committee size
    45 daysWritten recommendation deadline
    10 daysFinal decision deadline

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    NPDB and stateRequired reporting channels

    Appeal and Hearing Requirements

    Appeal and hearing eligibility

    A hearing is available when at least one of the following eligibility pathways applies:

    ONE of

    • The practitioner is a currently participating provider and the adverse action is based on a quality concern, regardless of product participation.

    • ALL of the following

      • The practitioner is a currently participating provider.
      • The adverse action is based on an administrative issue.
      • The practitioner holds a Medicare contract with Priority Health.
    • Priority Health terminates the Medicare contract of a participating practitioner for any reason, including a quality concern or administrative issue.

    Appeal deadlines and procedural requirements

    The practitioner must satisfy all of the following procedural requirements to preserve hearing and appeal rights:

    ALL of the following

    • Submit a written request for a hearing within 30 days after receiving notice of the Credentialing Committee recommendation.within 30 days
    • If a hearing is requested, the hearing date must be scheduled at least 30 days after the date of Priority Health's written hearing notice.at least 30 days after written notice
    • Confirm acceptance of the scheduled hearing in writing and identify any attorney or other representative within 15 days after the hearing date notice.within 15 days after hearing date notice

    Key Policy Definitions

    Quality concern
    DefinitionAn adverse action based on an internal-to-Priority Health quality concern or another event attributed to a Priority Health member.
    ApplicabilityQuality concerns may be attributed only to a currently participating provider, regardless of product participation.
    Distinguishing examplesExamples include internal evidence of substandard treatment, Priority Health member complaints or grievances related to quality, and malpractice judgments or settlements related to a Priority Health member.
    Administrative issue
    DefinitionAn adverse action based on an external-to-Priority Health event that is not attributed to a Priority Health member.
    ApplicabilityThe issue may involve a nonparticipating provider seeking initial credentialing or a currently participating provider seeking continued participation through recredentialing.
    Policy Summary
    PayerPriority Health Medicare
    PolicyDisciplinary Action & Practitioner Appeal Policy
    Policy CodePolicy 3240
    Change TypeNo material change
    Effective DateSep 8, 2026
    Next Review DateN/A
    Key ActionSubmit a written hearing request within 30 days after notice of the Credentialing Committee recommendation.
    SourceLink
    On This Page
    Appeal and Hearing RequirementsKey Policy Definitions
    Appear at the scheduled hearing unless there is good cause for failing to appear.

    Failure to meet any of these requirements results in waiver of hearing and appeal rights

    • The practitioner does not submit the written hearing request within 30 days after notice of the Credentialing Committee recommendation.
    • The practitioner does not timely confirm acceptance of the scheduled hearing in writing or identify an attorney or other representative.
    • The practitioner fails to appear at the scheduled hearing without good cause.
    Distinguishing examplesExamples include incomplete applications and failure to meet an Acceptance or Continued Participation Criterion.
    Appeal scopeOnly currently participating providers holding a Medicare contract with Priority Health are eligible to request a hearing for an adverse action based on an administrative issue.
    Appeal Committee
    Committee sizeThe Appeal Committee consists of not fewer than three and not more than seven in-plan practitioners.
    QualificationsMembers must have the appropriate expertise, qualifications, and experience to address the issues raised in the appeal.
    Peer statusMembers are peers of the appealing practitioner: appropriately licensed and trained practitioners in a practice similar to that of the appealing practitioner.
    Appointment authorityThe CMO or the CMO's designee appoints the members within 15 days of notification of the practitioner's intent to use the appeal process.
    Chair and participation limitsThe CMO designates one member as chair. Appeal Committee members may not be in direct economic competition with the appealing practitioner, and Credentialing Committee members may serve only if absent from the meeting that made the adverse-action recommendation.
    Direct economic competition
    DefinitionA circumstance in which a practitioner would be directly affected economically by the outcome of the appeal.
    Committee restrictionA practitioner in direct economic competition with the appealing practitioner may not participate in the Appeal Committee's review process.
    AttestationEach participating Appeal Committee member is asked to sign a statement indicating that the member believes they are not in direct economic competition with the appealing practitioner.