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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 providers, with cooperating partner networks and clients to resolve claim disputes. Please note, that Prime Health is unable to address questions regarding the application of bill review or state mandated fee schedule reductions. These questions should be directed to the insurance carrier and/or bill review vendor listed on your explanation of benefits/review. Prime Health is happy to assist in resolving claim disputes stemming from the application of a Prime Health network or Partner Network reduction.

Part of the nature of a Preferred Provider network is addressing, an industry average of 3% claim disputes. However Prime Health is proud to have a dispute average of 1.2%

The common reasons for a claim dispute to arise 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
  • Questions regarding the calculation of discount

To help ensure proper and quick resolution of the disputed claim, PHS 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
  4. Provide a contact name and number of person disputing

Providers may submit disputes via email claimdisputes@primehealthservices.com, or via fax to 615-329-4411. Providers with questions may also call our Claims Resolution Department at 1-866-348-3887. Prime Health is dedicated to a fast response for disputed claims which applied a Prime Health discount. Our average turnaround for dispute resolution is 5 to 7 business days.

Please also note that Prime Health is not the carrier and thus not the payer of claims. Any questions regarding payment status should be directed to the insurance carrier and/or bill review vendor listed on the corresponding Explanation of Benefits.