Seeing in prism why a claim denied is now easier than ever

It’s important to us that you understand how your claims were processed and why, and that you can find out easily. We know this information has been difficult to piece together from disparate resources in the past. That’s why we’re happy to share that we recently improved the Claims section in prism, pulling all claim denial details and rationale into one place. No additional buttons to click or external resources to access.

We hope this update will:

  • Support you in understanding how a claim processed, quickly and easily
  • Reduce the number of inquiries to our teams you need to submit and manage
  • Help you determine any next steps (i.e., submitting corrected claims or disputing a claim denial) more quickly

Reference prism for denial details instead of ERA/835 files

We highly recommend you reference prism to understand claim denials, not the CARC/RARC denial codes that appear on your electronic remittance advice (ERA/835) files. These CARC/RARC denial codes are generic while the prism denial codes are specific to the denied code and include denial rationale.

See how your claims processed, in prism

To see how your claim processed, and any denials that may have applied:

  1. Log into your prism account.
  2. Click Medical Claims under the Claims tab.
  3. Search for the claim in question and click the Claim ID.
  4. Scroll down to the Line Billed Detail and look for the Claim Line Explanation. There, you’ll now see the denial code, details and rationale – all in one place.

In some cases, when the rationale is lengthy, you’ll see a “see more” option to expand for further detail.