Medicaid post-claim appeals

This is your second opportunity to dispute a claim decision. You may appeal a claim only once.

If you’re not satisfied with the outcome of your Informal Claim Review, you can submit an appeal. By submitting a post-claim appeal, you’re formally requesting that we re-examine our initial adverse determination on an existing claim.

We won’t process your appeal if you haven’t completed the Informal Claim Review process first.

We only accept appeals from providers that performed the service.

Deadline for post-claim appeals

You must submit your appeal within 180 days of the remittance advice.

What will you need?

When you submit your appeal, 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 post-claim appeal

Make sure you've completed the Informal Claim Review process first. 

Process for in-network providers

  1. Log into your prism account.
  2. Click New Claim Appeal, then click on the claim number you wish to appeal.
  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 for your request as described above. 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

  6. Click Send. Your inquiry will appear in the Appeals list page upon submission.

Process for out-of-network providers

The servicing provider must either complete and submit the Level I appeal form or submit an appeal letter.

After submitting your appeal

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 or by adverse determination letter within 30 calendar days of the submission.