Appeal vs. claims inquiry: Steps for faster claims resolution

As of 11/01/2021, providers have one appeal right for each Priority Health claim. Any future claim corrections performed in the remaining 12 months won't result in additional appeal rights.

With only one appeal right per claim, we ask you to follow the steps below for a faster claim resolution prior to submitting an appeal. It’s important to us that you’re satisfied with the way a claim is handled. If you have a problem, we want you to know what you can do about it.

Step 1: Check the status of your claim

To check the status of your claim:

  1. Log into your prism account
  2. Click Claims then Medical Claims
  3. Select the Claim ID in question on the righthand side. You can search for claims by entering member information and date of service.

There you'll find the most up to date billing information, claim status and tools available for you to get answers.

Step 2: Submit an informal claim review

To let us know you'd like our Provider Operation team to review a claim:

  1. Log into your prism account
  2. Click Claims then Medical Claims
  3. Select the Claim ID in question on the righthand side. You can search for claims by entering member information and date of service.
  4. Click Contact us about this claim
  5. Select Other related claims questions in the dropdown
  6. Enter your information and submit

With only one appeal right per claim, we ask that you use this informal claim review process for general questions on a claim such as a claim process, APC edit, billing questions and ect. 

Step 3: File an appeal

If the informal claim review doesn't resolve the problem, there's a formal appeal process you can follow.

Appeals will now only be reviewed after an informal claim review. You need to submit at least one inquiry to try to resolve an issue prior to submitting an appeal.

Be sure to review each appeal submission carefully. We process every appeal we receive. This is important to note because there are many third-party billing companies accessing prism on behalf of our providers. If an appeal is submitted by mistake, we'll still treat it as an official appeal and comment back with provider education and close the inquiry. There won't be an opportunity for another appeal on that claim.