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Prime Health Services

Claim Dispute Resolution

Prime Health Services has a dedicated repricing and reconsideration department who work on behalf of our clients, with providers and cooperating partner networks to resolve claim disputes.

The goal at Prime Health is to have all clean claims with no disputes and no reimbursement issues. However, part of the nature of a PPO network is addressing, an industry average of 3% claim disputes. Prime Health is proud to have an average of 1.2% claim disputes.

There are several common reasons for a claim dispute to arise are, which are:

  • The EOB/EOR (Explanation of Benefits / Review), does not properly list Prime Health or our Partner Network
  • Provider does not recognize their contract with Prime Health or our Partner Network
  • An error in repricing the claim occurs with Prime Health or client

To help ensure proper and quick resolution of the disputed claim, Prime Health requests that the following information be included when submitting a dispute:

  1. Provider name / or patient name in the subject line
  2. A copy of the EOB/EOR and corresponding claim form being disputed
  3. Provide a brief explanation of the dispute, or the actual appeal letter
  4. Provide a contact name and number of person disputing

Clients may submit disputes via email, or via fax to 615-329-4411. Clients with questions may also call our Claims Resolution Department at 1-866-348-3887.

Prime Health is dedicated to the fast response of disputed claims which applied a Prime Health discount. Our average turnaround for dispute resolution is 3 to 5 business days. Upon resolution of the claim dispute, clients will be advised in writing an explanation of the resolution and instructions if further reconsideration is necessary.