Any initial request to have your claim reviewed

Complex claim reviews

For fastest response, use this process.
  1. Log into your prism account
  2. On the Claims tab (medical), find the claim on the claims listing page. Click on the claim ID link.
  3. On the Claims Detail page, click Contact us. Choose “Other related claims questions" in “What is your message about”.
  4. Your inquiry will appear within the General Request list page upon submission.
  5. A provider operations analyst will respond to your inquiry via comments within 15 calendar days. You’ll receive an automated email notification when a comment has been entered on your inquiry.
  6. If your inquiry requires investigation by another department, we'll notify you via comments within 15 calendar days.
  7. If you have not received a response within 15 calendar days send an email to exceedsprocessingtime@priorityhealth.com and include your inquiry number.
  8. If you're not satisfied with the outcome of the informal review, you can file a Level I appeal.

Coding or clinical edit question reviews

  1. Log into your prism account
  2. On the claims tab (medical), find the claim on the claims listing page. Click on the claim ID link.
  3. On the Claims Detail page, click Contact us. Your inquiry will appear within the General Request list page upon submission.
  4. The Clinical edit choice is only applicable when line in question has a clinical edit. Verify the claim edit is present by using the clinical edit column in the claims tool. See example below:

    Claim-edit-example

    Do not use Clinical Edit drop-down if N/A is listed in the clinical edit column.

    clinical edits NA
  5. A coding analyst will reply with an explanation within 45 business days.
  6. If you haven't received a response within 45 days,  send an email to exceedsprocessingtime@priorityhealth.com and include your inquiry number
  7. If you're not satisfied with the informal review explanation, you can file a Level I appeal.

Third party liability (TPL)

Only utilize this drop-down option when the claim denied for TPL investigation/TPL primary and you're submitting documentation for our Third Part Liability department to review.

  1. Log into your prism account
  2. On the claims tab (medical), find the claim on the claims listing page. Click on the claim ID link.
  3. On the Claims Detail page, click Contact us. Select Third party liability (TPL) option for What is your message about. Complete the fields and click send.
  4. Your inquiry will appear within the General Request list page upon submission.

Coordination of benefits (COB)

Only utilize this drop-down option when the claim denied for COB investigation/other insurance primary information and you're submitting documentation for our COB department to review. IE primary EOB, documentation no other insurance for member etc.

  1. Log into your prism account
  2. On the claims tab (medical), find the claim on the claims listing page. Click on the claim ID link.
  3. On the Claims Detail page, click Contact us. Select Coordination of benefits (COB) option for What is your message about. Complete the fields and click send.
  4. Your inquiry will appear within the General Request list page upon submission.

Submitting medical records

When you request an authorization, or a post payment appeal determination, you may need to send us medical records.

To submit medical records for a specific claim (post-claim):

  1. Log into your prism account
  2. On the claims tab (medical), find the claim in the claims listing page. Click on the claim ID link. 
  3. On the Claim Details page, click Contact us. In the drop-down menu, select Submit medical records.
  4. Make sure to choose the correct line item. Attach medical records to your message.
  5. Your inquiry will appear within the Appeals list page upon submission

To submit medical records that are for preexisting conditions only:

 (Do not use to submit additional documentation for a pending prior authorization)

  1. Log into your prism account
  2. Click the General Requests tab
  3. Click on the New Request button and choose Pre-existing medical record submission
  4. Enter a message including the member name, date of birth and member ID
  5. Upload and attach your supporting documentation
  6. Your inquiry will appear within the General Requests list page upon submission

To request a new pre-claim appeal:

Appeal, pre-claim inpatient emergent: use when acute inpatient authorization (admitted through ED or conversion from outpatient surgery) has been denied and no claim has been submitted.

Appeal, pre-claim inpatient elective: use when to Elective Inpatient authorizations that have been denied preservice and no claim has been submitted. **Don't submit acute or emergent inpatient admissions here.

Appeal, pre-claim outpatient: use when outpatient medical authorizations that have been denied preservice and no claim has been submitted.

  1. Log into your prism account
  2. Click on the Appeals tab
  3. Click on the New Pre-Claim Appeal button
  4. Choose the most appropriate Request Type
  5. Enter in the required fields, upload and attach supporting documentation
  6. Your inquiry will appear within the Appeals list page upon submission