Reviews of provider appeals for complex claims and medical necessity denials for commercial plans

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. You'll get an automated response with a claim inquiry reference number.
  4. A provider operations analyst will respond to your inquiry via comments within 15 calendar days.
  5. If your inquiry requires investigation by another department, we'll notify you via comments within 15 calendar days.
  6. If you have not received a response within 15 calendar days send an email to exceedsprocessingtime@priorityhealth.com and include your inquiry number.
  7. 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. You'll get an automated response with a claim inquiry reference number.
  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.

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.

Other related claims questions

Use this drop down option when your question isn't covered by any other available selection.

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.
  5. Attach medical records to your message.
    You'll receive a confirmation screen after submitting your message, and a confirmation email from our Provider Services team

To submit medical records that are not related to a specific claim (pre-claim):

  1. Log into your prism account
  2. Click the Messages tab
  3. In the What is your message about? field, choose Medical record submission (pre-existing)
  4. Use the Attachments field to attach your documents
  5. In the body of the email include: member name, DOB and member ID number
  6. If you're submitting a pre-claim appeal, you must complete and attach the most current Priority Health appeal form and submit a detailed letter of appeal. For more information on appeals, access our Reviews and appeals requirements