Level I medical authorization appeal
Situation
You received a denial from the initial prior authorization review and haven't yet performed the service.
Deadline
Appeal the medical authorization denial within 65 days from notice of initial determination.
Process
- Log into your prism account.
- Click the Appeals tab.
- Click New Pre-Claim Appeal.
- Choose the most appropriate request type and enter in the required fields. Upload clinical documentation to support your appeal.
- Click Submit.
After submission
Your request will appear in the Appeals List page in prism after you click Submit. We’ll inform you of our decision either by remittance advice or by adverse determination letter within 30 calendar days of submission. If we uphold the denial, you have the option of filing a Level II medical authorization appeal.
Level II medical authorization appeal
Situation
You received a denial on your Level I medical authorization appeal
Deadline
Within 30 days of adverse Level I appeal decision
Process
- Log into your prism account.
- Click the Appeals tab.
- Click New Pre-Claim Appeal.
- Choose the most appropriate request type and complete the required fields, uploading supporting documentation.
- Click Submit.
After submission
Your request will appear in the Appeals List page in prism after you click Submit. After the Level II appeal is submitted, we'll make a determination within 30 days of receipt. We’ll inform you of our decision either by remittance advice or by adverse determination letter within five business days of the decision.