How to submit your request

1. Log into your prism account. Make sure you’re logged in as the group or facility the claim was paid under.
2. Under the Claims tab click Medical Claims.
3. Find the claim in question on the claims listing page. You can use the search bar in prism to enter your Claim ID or any element on the claims list page to filter your claims. When you find the right claim, click on the Claim ID link.
4. On the Claims Detail page, click Contact Us About This Claim. This will open a new window.
5. Choose “Other related claims questions" in the “What is your message about” drop-down menu.
6. Complete all fields, attach any documentation, write us a message and click Send.

What happens after you click send?

Your inquiry will appear in the General Requests section of prism after submission. We’ll respond to your inquiry within 15 calendar days. To see our response in prism, go to General Requests, open the inquiry and look at the Comments section. You’ll receive an automated email notification when a comment has been entered on your inquiry.

If your inquiry requires investigation by another department, we'll notify you via comments within 15 calendar days.

If you haven’t received a response within 15 calendar days, email us at exceedsprocessingtime@priorityhealth.com and include your inquiry number.

If you're not satisfied with the outcome of the informal claim review, you can file a Level I appeal.

Itemized Bill Reviews (IBR)

Follow this Informal Claim Review process to submit questions related to Itemized Bill Reviews (IBR). After you submit your inquiry, we’ll follow up with a detailed breakdown of the review outcome, routing any further questions to our Payment Integrity team.

Follow this process when the claim line in question has a clinical edit. Verify the claim edit is present on the Claims Detail page in prism by looking for the “See edits” button under the Clinical Edit column. Don’t use this process if the button isn’t there.

How to submit your request

1. Log into your prism account.
2. Under the Claims tab, click Medical Claims.
3. Find the claim in question on the claims listing page. You can use the search bar in prism to enter your Claim ID or any element on the claims list page to filter your claims. When you find the right claim, click on the Claim ID link.
4. On the Claims Detail page, click Contact Us About This Claim. 
5. Choose “Clinical Edit" in the “What is your message about” drop-down menu.
6. Complete all fields, attach any documentation, write us a message and click Send.

What happens after you click send?

Your inquiry will appear in the General Requests section of prism after submission. We’ll respond to your inquiry within 60 calendar days. To see our response in prism, go to General Requests, open the inquiry and look at the Comments section. You’ll receive an automated email notification when a comment has been entered on your inquiry.

If you haven’t received a response within 60 business days, email us at exceedsprocessingtime@priorityhealth.com and include your inquiry number.

If you're not satisfied with the informal claim review explanation, you can file a Level I appeal.

Only use the “Third party liability (TPL)” drop-down option when the claim denied for TPL investigation/TPL primary and you're submitting documentation for our Third Party Liability department to review.

How to submit your documentation for TPL review

1. Log into your prism account.
2. Under the Claims tab, click Medical Claims.
3. Find the claim in question on the claims listing page. You can use the search bar in prism to enter your Claim ID or any element on the claims list page to filter your claims. When you find the right claim, click on the Claim ID link.
4. On the Claims Detail page, click Contact Us About This Claim. 
5. Choose “Third party liability (TPL)" in the “What is your message about” drop-down menu.
6. Complete all fields, attach any documentation, write us a message and click Send. Your inquiry will appear in the General Requests section of prism after submission.

Only use the “Coordination of benefits (COB)” drop-down option when the claim has been denied for COB investigation/other insurance primary information and you're submitting documentation (i.e., primary insurance EOB or documentation of no other insurance coverage for a member etc.) for our COB department to review.

1. Log into your prism account.
2. Under the Claims tab, click Medical Claims.
3. Find the claim in question on the claims listing page. You can use the search bar in prism to enter your Claim ID or any element on the claims list page to filter your claims. When you find the right claim, click on the Claim ID link.
4. On the Claims Detail page, click Contact Us About This Claim.
5. Choose “Coordination of benefits (COB)" in the “What is your message about” drop-down menu.
6. Complete all fields, attach any documentation, write us a message and click Send. Your inquiry will appear in the General Requests section of prism after submission.

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. Under the Claims tab, click Medical Claims.
3. Find the claim in question on the claims listing page. You can use the search bar in prism to enter your Claim ID or any element on the claims list page to filter your claims. When you find the right claim, click on the Claim ID link.
4. On the Claim Details page, click Contact Us About This Claim.
5. Choose "Submit medical records" in the "What is your message about" drop-down menu.
6. Complete all fields, making sure to choose the correct line item. Attach medical records, write us a message and click Send. Your inquiry will appear within the Appeals list page in prism upon submission.

To submit medical records that are for preexisting conditions only:

Don't use to submit additional documentation for a pending prior authorization.

1. Log into your prism account.
2. Click the General Requests tab.
3. Click on the New Request button and choose "Pre-existing medical record submission" from the menu.
4. Enter a message including the member name, date of birth and member ID. Attach your supporting documentation and click Send. Your inquiry will appear within the General Requests list page in prism upon submission.

To request a new pre-claim appeal:

Appeal, pre-claim inpatient emergent: use when acute inpatient authorization (admitted through ED or conversion from outpatient surgery) has been denied and no claim has been submitted.

Appeal, pre-claim inpatient elective: use when to Elective Inpatient authorizations that have been denied preservice and no claim has been submitted. **Don't submit acute or emergent inpatient admissions here.

Appeal, pre-claim outpatient: use when outpatient medical authorizations that have been denied preservice and no claim has been submitted.

1. Log into your prism account.
2. Click on the Appeals tab.
3. Click on the New Pre-Claim Appeal button.
4. Choose the most appropriate Request Type.
5. Enter in the required fields, upload and attach supporting documentation. Click Send. Your inquiry will appear within the Appeals list page upon submission.