This is your second opportunity to dispute a claim decision. You may submit a Level 2 claim dispute (formerly called Appeal) only once per claim.
We won’t process your Level 2 claim dispute if you haven’t completed the Level 1 claim dispute process first.
If you’re not satisfied with the outcome of your Level 1 claim dispute decision, you can submit a Level 2 claim dispute. By submitting a level 2 claim dispute, you’re formally requesting that we re-examine our initial adverse determination on an existing claim.
We only accept Level 2 disputes from providers that performed the service.
Deadline for Level 2 claim disputes
You must submit your Level 2 dispute within 180 days of the remittance advice.
What will you need?
When you submit your Level 2 dispute, you must upload additional documentation to support the services rendered or payment expected. Here’s our tips for choosing what documents to upload:
- Make sure the documentation supports the appeal
- Send final documents only, not preliminary results
- Only send paperwork related to the specific date of service in question
- Send only what’s relevant – we don’t need discharge paperwork, service orders etc. Don’t include corrected claims or new claims to be processed.
In addition to supporting documentation, you’ll also need to upload:
- Provider appeal letter
- Priority Health denial letter (recommended)
How to submit a Leve 2 claim dispute
Make sure you've completed the Level 1 claim dispute process first.
Process for in-network providers
- Log into your prism account.
- Click Appeals and then New Post-Claim appeal, then search for and click on the claim number you wish to appeal.
- On the Claims Detail screen, click Contact us about this claim.
- In the drop-down menu, select Appeals.
- Enter your name, phone number, message – including the disputed code – and attachments. Make sure to include supporting documentation (see below) for your request as described above.
Supporting documentation can include contract language, CMS information, proof of timely filing, etc. We won't accept the following as supporting documentation: remittance advice, a copy of a claim, a system print out – we'll close the inquiry. Additionally, we only accept medical records for claim appeals determining medical necessity or when specifically requested.
Also include the following, as appropriate:
Specifics on what was denied and the cited reason for denial
Fee schedules
Any justification that supports your appeal - Click Send. Your inquiry will appear in the Appeals list page upon submission.
Process for out-of-network providers
- Fastest (preferred): The servicing provider submits the Level 2 claim dispute through prism, using the process outlined above. Any provider can create a prism account. If you don't have one already, create one now.
- Alternative: The servicing provider must either complete and submit the Level 2 claim dispute form or submit an appeal letter.
After submitting your Level 2 claim dispute
We’ll review the contractual, benefit claims and medical record information.
We'll inform you of the outcome of our review either by remittance advice, adverse determination letter or via a comment on the inquiry in prism within:
- 60 calendar days of the submission for coding / clinical edit disputes
- 45 calendar days of the submission for all other claim disputes
- 60 calendar days of the submission for medical necessity appeals