Appeal Rights

The claims dispute process is as follows:

An appeal must be received in writing within 180 calendar days from the date on the RA. Verbal requests must still also be filed in writing within the 180-calendar daytime frame. A claims dispute must be submitted if one disagrees with full or partial claim rejection or denial, or the payment amount.

Once appeal is submitted, the decision will be reviewed, and a written determination will be completed within 30 days. If the payment, coverage, or service requested continues to be denied or a timely decision is not provided, a second appeal may be submitted within 30 days of the notice of denial. Again, a written determination will be provided within 30 days.

Prime UR strives to provide careful consideration and resolution in a reasonable time.

Using the correct forms with timely submission makes the process go more smoothly.

Send the appeal in writing that identifies the claim decision to deny payment, service or coverage, and any supporting documentation to the address or fax as shown on the Dispute Appeal form.

Provider Dispute and Resolution Form

  1. Submit your appeal in writing. Verbal appeals cannot be filed and processed
  2. Please submit supporting clinicals to be processed

Submit form completed with all information

By Mail
Keenan EBTPA
Attn: Provider Disputes
P.O. Box 2744
Torrance, CA 90509

By Fax
310-533-5755

For Questions Only (Not Submissions) Call 888-773-7218

Provider Dispute Resolution Process

Note: Providers receive notification by mail when a determination is made, usually within 30 days

Medication/Pharmacy Appeals:

The following applies when a prior authorization request is denied by Express Scripts:

An appeal must be received from the prescribing physician within 180 calendar days from the date on the denial. When submitting the appeal please include the denial letter, sent by Express Scripts, with your request. The appeal needs to be sent to:

Click here to download the form:

EHP
PRIME HEALTHCARE – EE HEALTH PLAN
3480 E. GUASTI ROAD
ONTARIO, CA 91761
Fax 1: 909.235.4397

Once the appeal is submitted, the decision will be reviewed, and a written determination will be completed within 30 days. If the payment, coverage, or service requested continues to be denied or a timely decision is not provided, a second appeal may be submitted within 30 days of the notice of denial. Again, a written determination will be provided within 30 days.

Prime EHP strives to provide careful consideration and resolution in a reasonable time.

Providing the denial letter with timely submission makes the process go more smoothly.