Appeals & Grievances

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

Practitioners and providers have 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.

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

Appeals and Grievances Form

Appeals and Grievances Providers (Pharmacies/Pharmacists)

Presbyterian Health Plan and Presbyterian Insurance company manages all appeals and grievances for providers (pharmacies/pharmacists) related to coverage determinations and the formulary review process. Certain specialized services and prescription drugs require a prior authorization or inpatient notification before being rendered to patients and members.

For pharmacy related prior authorization information visit our Authorizations page

OptumRx manages all appeals and grievances for Pharmacies and Pharmacists that relate to policies and procedures in accordance with participating pharmacy provider network agreements including the following:

• Term definitions
• Contract information
• Processing Claims
• BIN information
• Compliance, fraud, waste and abuse (FWA)
• Pharmacy network participation requirements
• MAC Appeals

Provider manual (optumrx.com)

• Provider Appeal and Grievance Processes
• Applicab​le Appeal and Grievance Regulations

Pharmacies or Pharmacists can submit MAC Appeal Requests by visiting the OptumRx website here:

MAC appeal submission guide (optumrx.com)

Should a pharmacy or pharmacist disagree with any policy, decision or adverse action made by Presbyterian, they can contact the Provider CARE Unit at 505-923-5757 or 1-888-923-5757 or your Provider Network Management Relationship Executive.

Appeals & 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 are provided in the following documents:

• Provider Appeal and Grievance Processes
• Provider Credentialing Dispute Process
• Member Appeal and Grievance Processes
• Applicab​le Appeal and Grievance Regulations

Should a provider/practitioner disagree with any policy, decision or adverse action made by Presbyterian, he/she should contact the Provider CARE Unit at 505-923-5757 or 1-888-923-5757 or your Provider Network Management Relationship Executive. They will put you in touch with the appropriate audience to hear your appeal. Appeals are heard by: