Reminder: Informal claim reviews are required before appeals

It’s important to us that we accurately process your claims, and you understand the way your claims are handled.

To support you through the claim dispute process to make sure your questions / concerns are addressed in a timely manner – and you’re paid accurately and fairly for the care you’ve provided to our members – we’re sharing a few reminders and tips for our claim review and appeal process.

Understand how your claim processed

In prism, you can see exactly how a claim processed and, if it was denied, why. To do this:

  1. Log into your prism account.
  2. Under the Claims menu, click Medical Claims.
  3. Search for and click the Claim ID in question.
  4. Scroll down to see line paid details, including any denial explanation. If a clinical edit applied to the claim, a See Edits button will appear, which takes you to an explanation of the edit(s).

If you’re unable to find the information you need in prism, you can reach out to our teams for help. Learn how.

Follow our two-step claim dispute process

The claim dispute process includes two steps:

  1. Informal claim review – This step, including a review decision from our team, is required before an appeal can be processed. You must wait 45 days after submitting a claim, to allow claim processing, before submitting a claim review asking us to reconsider our decision on a claim. This may include a comprehensive review, coding / clinical edit questions, third party liability, coordination of benefits and more.
  2. Claim appeal – If you’re unsatisfied with the outcome of the claim review, you can submit an appeal. Appeals can dispute payment issues, clinical edits and claim denials. Please note, you have one appeal right per claim. Any future claim corrections won’t result in additional appeal rights.

Review tips & tricks

We recently updated our claim reviews and appeals tipsheet to include even more helpful information, including answers to common questions like:

  • What’s the difference between a claim review and appeal, and when can you use them?
  • What makes a good appeal?
  • What sort of documentation can you submit with an appeal?
  • What about reviews for multiple claims?
  • And more