Provider Appeals and Grievances

Presbyterian Health Plan welcomes feedback from our providers. We have very comprehensive processes implemented, in conjunction with our regulatory agencies, to ensure that our members and providers have grievances and appeals rights.

A provider/practitioner has the right to file an Appeal if he/she is dissatisfied with a decision made by Presbyterian to terminate, suspend, reduce or not provide approved services to a member or to deny payment for services, and if the provider disagrees with any policy or adverse action made by Presbyterian. Additionally, if a provider/practitioner is dissatisfied with any of Presbyterian’s general operations, he/she may file a Grievance.

File an "Appeal or Grievance" online

Providers have 1 year (12 months) from the date of service to file an appeal for a denied claim.

Appeals and Grievances on Behalf of Members

If an issue involves a Utilization Management decision, a practitioner or provider must obtain the written consent of the member to act on his/her behalf during the appeal process, unless the matter is determined to be an Expedited Appeal.

Detailed information on the appeals and grievances processes can be accessed below (all documents are Adobe Acrobat .pdf files): 

• Provider Appeal and Grievance Processes 
• Provider Credentialing Dispute Process 
• Member Appeal and Grievance Processes
• Applicable Appeal and Grievance Regulations

Contact List

Should a provider/practitioner disagree with any policy, decision or adverse action made by Presbyterian, he/she should contact the following individuals:

*Provider and Member Appeals and Grievances Coordinators may be reached by contacting the Provider CARE Unit at (505) 923-5757 or 1-888-923-5757, or your Provider Services Coordinator.

Copies of Appeals and Grievances Policies and Procedures for Member Standard and Expedited Appeals, Member Grievances, Provider Grievances and Appeals, may be requested through the Provider Care Unit.