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. 

If you’re not satisfied with the outcome of your Level 1 claim dispute decision, you can submit a Level 2 claim dispute. A Level 1 claim dispute decision is needed in prism before you can submit a Level 2. 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?

• Claim ID for the most current claim. We’ll close claim disputes without review when a claim is resubmitted after the dispute was filed.
•  
• Denial reason applied to the claim or claim line.
• Attach any Policy or clinical guidelines applicable to the denial.
• Attach any regulatory, billing, coding guidelines or contract language.
• Supporting documentation applicable to the service under dispute. We’ll close claim disputes submitted with the full medical record.
• Summary of why you believe the claim didn’t process in accordance with the guidelines, policy and/or contract. This should be very specific. We’ll close claim disputes with statements such as “this is coded correctly” or “please review records” as these don’t support a claim dispute rationale.

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

1. Log into your prism account.
2. Click Appeals and then New Post-Claim Appeal then search for and click on the claim number you wish to dispute.
3. On the Claims Detail screen, click Contact us about this claim.
4. In the drop-down menu, select Appeals.
5. 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.
   1. Note: 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 don't accept medical records for claim appeals unless specifically requested.
6. Click Submit. Your inquiry will appear within 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 Out-of-network/Out-of-state provider 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
• 60 calendar days of the submission for medical necessity appeals
• 45 calendar days of the submission for all other claim disputes