Medicaid post-claim informal claim reviews

Waiting period

You must wait 45 days after submitting a claim to request a review, and a review decision is required before you can file an appeal.

This is your first opportunity to dispute a claim decision.

For Commercial and Medicaid post-claim disputes, your first step is to submit an Informal Claim Review request. Below are the processes to do just that, broken down by the reason for your request. We won’t accept an Appeal on a claim until this Informal Claim Review process is complete.

Complex claim reviews

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.

Coding or clinical edit question reviews

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.

Third party liability (TPL)

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.

Coordination of benefits (COB)

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.