Waiting period
You must wait 45 days after submitting a claim to submit a Level 1 claim dispute (formerly called Review) and a decision is required before you can file a Level 2 claim dispute (formerly called Appeal).
This is your first opportunity to dispute a claim decision.
For commercial and Medicaid post-claim disputes, your first step is to submit an Level 1 claim dispute. Below is the process to do just that. We won’t accept a Level 2 claim dispute until this process is complete.
Level 1 claim disputes
How to submit your request
- Log into your prism account. Make sure you’re logged in as the group or facility the claim was paid under.
- Click Claims in the main menu.
- Find the claim in question on the claims listing page. You can use the search bar in prism to enter your Claim ID or any element on the claims list page to filter your claims. When you find the right claim, click on the Claim ID link.
- On the Claims Detail page, review the claim details, including the description of any clinical edits that may have applied. If you still have a question, click Contact Us About This Claim. This will open a new window.
- Choose one of the following options from the "Question about my claim" button at the top of the screen, in the drop-down menu.
- Question about my claim (Level 1 Dispute) - appropriate when questions are related to payment, coding, or clinical edit criteria applied. Not be used when claims are denied due to inaccurate coding or billing by the provider.
- Appeals (Level 2 Dispute) - appropriate when the claim submitted aligns with billing and coding policies, but the provider has identified an error or inconsistency against our policies.
- Complete all fields, attach any documentation, write us a message and click Send.
What happens after you click send?
Your inquiry will appear in the General Requests section of prism after submission. We’ll respond to your inquiry within the following timelines:
- 15 calendar days - Questions about your claim (Level 1 Claim Dispute)
- 60 calendar days - Appeals (Level 2 Claim Dispute)
To see our response in prism, go to General Requests, open the inquiry and look at the Comments section. You’ll receive an automated email notification when a comment has been entered on your inquiry.
If your inquiry requires investigation by another department, we'll notify you via a comment on your inquiry within the above timeframes.
Claim review process
Claims are reviewed and responded to in the order they were received within the above timeframes. Claim reviews can’t be escalated by emailing us for an update on your claim.
If you encounter an issue with over 100 claims, and you have already submitted at least one Level 1 Claim Dispute, you can email us at exceedsprocessingtime@priorityhealth.com with that inquiry number. All other emails sent will receive a response that we are processing inquiries per our first-in-first-out policy.
Itemized Bill Reviews (IBR)
Follow this Level 1 claim dispute process to submit questions related to Itemized Bill Reviews (IBR). After you submit your inquiry, we’ll follow up with a detailed breakdown of the review outcome, routing any further questions to our Payment Integrity team.
Third-party liability (TPL)
Follow this Level 1 claim dispute process when the claim denied for TPL investigation/TPL primary and you're submitting documentation for our Third-Party Liability department to review.
Coordination of benefits (COB)
Follow this Level 1 claim dispute process when the claim has been denied for COB investigation/other insurance primary information and you're submitting documentation (i.e., primary insurance EOB or documentation of no other insurance coverage for a member etc.) for our COB department to review.