Currentpriority healthPolicy N/A

Member Appeal Submission Process and Procedures

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Governs how members (or their authorized representatives) submit appeals for adverse benefit determinations, timelines for pre- and post-service appeals, required form elements, and urgent appeal procedures. Affects members of plans administered by Healthcare Management Administrators (HMA) and their representatives.

Policy Summary

Payerpriority health

PolicyMember Appeal Submission Process and Procedures

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Member Appeal Submission Form (or signed written statement) with supporting documentation within 180 days of the initial adverse determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

180 daysdeadline to submit Form from initial adverse determination

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Currentpriority healthPolicy N/A

Member Appeal Submission Process and Procedures

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Sign up for all priority health policy alerts

Know when priority health releases new policies or updates existing guidance.

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Policy Summary

Payerpriority health

PolicyMember Appeal Submission Process and Procedures

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Member Appeal Submission Form (or signed written statement) with supporting documentation within 180 days of the initial adverse determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

180 daysdeadline to submit Form from initial adverse determination

Appeal Submission Criteria and Procedures

Appeal submission criteria and procedures

Required elements and process for filing an appeal

Completed Member Appeal Submission Form and/or a signed written statement is required; each appeal level must be submitted using a separate Form (i.e., a new Form is required for second-level and for Federal External Review).

Include all facts and theories supporting the claim and a clear, concise statement of the reason(s) for disagreement; attach any material that indicates entitlement to benefits (e.g., medical records, chart notes, physician letters).

Form must be received within 180 calendar days of the initial adverse benefit determination; failure to file timely will bar further review under these procedures or in court.

Member must select one method for notification of the outcome: email, fax, or mail (to the address provided on the Form).

Authorized representative

A member may appoint one authorized representative (such as a provider, power of attorney holder, court‑appointed guardian, or other designated individual).

Appeal levels

First-level Appeal: you have not previously submitted an appeal.
Second-level Appeal: you previously submitted an appeal and it was denied; submit a new Form to request second-level review.
Federal External Review (FER): available after first and second-level appeals are both denied; requires separate submission.

Urgent (pre-service) appeals

Pre-service urgent appeals may be made verbally by calling the Appeals department at 800-869-7093.
If claiming urgent pre-service status on the Form, physician certification is required demonstrating the DOL urgent criteria (application of time periods could seriously jeopardize life or health, ability to regain maximum function, or cause severe unmanaged pain); physician must sign the urgent certification section.
Turnaround for pre-service urgent appeals: 72 hours.

Submission methods: Online DocuSign via mi.accesshma.com (Download Member Forms), PDF/email to appeals@accesstpa.com, fax to 855-462-8875, or mail to Appeals Department, HMA, PO Box 85016, Bellevue WA 98015-5016. Providers may assist by completing and signing forms.

Signatures required: patient or parent/guardian signature is required on the Form; physician signature is required for the urgent pre-service certification.

Attachments: include all relevant materials with the submission; failure to include necessary material could delay processing or result in denial.

Processing timeframes: pre-service urgent 72 hours; pre-service standard 15 days; post-service first and second levels 30 days; Federal External Review 45 days.

Scope and limitations: the appeal may challenge denials in whole or in part and may address copayments, deductibles, coinsurance, eligibility, benefits, or pre-authorizations; the member's Plan SPD may contain different or additional appeal rights—refer to the SPD for more information.

Turnaround Times and Coding Notes

Not specifiedmixed

No codes listed

Turnaround times

Urgent pre-service72 hours

Standard pre-service15 days

Post-service (first and second level)30 days

Federal external review45 days

Provider Responsibilities and Submission Options

Documentation Required

Urgent pre-service physician certification — physician must certify and sign

The attending physician must complete and sign the Urgent Pre-service Appeal Physician Certification section attesting that the requested service meets the DOL definition of 'urgent' and that the adverse determination is for a pre-service request. The signed certification must include physician contact information and signature/date in the Physician Office/Staff - Direct Contact Information and Physician Signature fields.

Must meet DOL urgent definition: time periods if not shortened could seriously jeopardize life or health, ability to regain maximum function, or cause severe unmanaged pain per a physician.
Adverse determination must be for services not yet performed (pre-service).
Physician must provide direct contact info and sign/date the certification attesting to accuracy.

Prior Authorization

Submission options — providers may complete/sign and submit forms

Key Definitions

Pre-service

DefinitionPre-service — Service has not yet been provided.

ContextUsed to determine if urgent pre-service procedures apply.

Related actionPre-service appeals follow the 72-hour (urgent) or 15-day (standard) timelines.

Post-service

DefinitionPost-service — Service has already been provided.

Appeal levelsPost-service appeals proceed through first and second levels; each level has a 30-day timeframe.

Further reviewAfter first and second level denials, federal external review is available with a 45-day timeframe.