Please CLICK HERE to download a copy of the detailed FAQs that provide information about the Authorization process and charts.

The Prime Healthcare Prime EPO Plan

Why have we designed the Prime Healthcare EPO Plan?

Prime Healthcare established a self-funded medical Prime EPO Plan for you, our valued employees. Providing you healthcare services at our own award-winning hospitals (Tier 1 Prime Healthcare Network) is an honor and allows us to offer high quality care to you and your families, and savings that are passed on directly to you at no or little cost with low out-of-pocket charges and minimal employee payroll contributions.

How does the Prime Healthcare EPO Plan compare to other medical plans?

The Prime Healthcare EPO Plan is among the best offered. It offers a high-quality plan and an award-winning network of hospitals and providers at the lowest costs to its members and provides value that is greater than a PPO plan. The Prime EPO Plan covers 100% of preventive care charges and most inpatient and outpatient hospital-based services within the Tier 1 Prime Healthcare Network, at little to no cost. Tier 1 includes Prime’s own award-winning hospitals and physicians and is growing daily to provide even more services. Most of all, the plan strives to provide exceptional care to employees and covered dependents, who are valued members of our own Prime Healthcare family.

What is the Tier 1 Prime Healthcare Network?

The Tier 1 Prime Healthcare Network (Tier 1 Network) is a directory of primary care, durable medical equipment, and specialty physicians who accept the Prime EPO Plan. Most have admitting privileges at our Prime hospitals. We are continuously growing the Network to better serve you and provide the best benefits possible.

Physicians and Providers

Who is considered a Primary Care Provider?

A Primary Care Provider (PCP) is defined as: General Practitioner, Family Practice, OB/GYN, General Pediatrician and Internal Medicine. Establishing a primary care provider ensures you have a physician dedicated to coordinating your medical care and ensuring the quality of care you receive.

Where can I find a list of physicians in the Tier 1 Prime Healthcare Network?

The Tier 1 Prime Provider Directory is available on the EHP website at www.primehealthcare.com/EHP. If you need help with how to find a Tier 1 provider, please call Prime Customer Service at 877-234-5227 for assistance.

How often are the online Provider directories and the Find a Provider tool updated?

The online directories are updated online once a month by the 15th of month.

Why can’t I locate the Tier 1 Provider that I was directed to online?

The online directories are updated on our website located at www.primehealthcare.com/EHP once a month. The Provider you were referred to may have recently joined the network or been added to a Provider’s office and not yet been updated and loaded to the website yet.

How can my provider join the Tier 1 Prime Healthcare Network?

Recognizing that many of our employees have long-standing relationships with providers, these providers are welcome to join the Prime Healthcare Network. To nominate a provider download the form from our website at www.primehealthcare.com/ehp, email your request to EHPprovidercontracts@primehealthcare.com, and a representative will reach out to your provider. Members are welcome to share this email address with your providers.

Do physicians pay a fee to join the Tier 1 Prime Healthcare Network?

No. There is no cost to join the Prime Healthcare Network.

Am I required to see a Tier 1 Prime Healthcare Primary Care Physician (PCP)?

Ideally, to stay within the Prime Healthcare Network at the lowest cost to you, you would select a Tier 1 Primary Care Provider. However, you may designate a Primary Care Physician from the Tier 2 Blue Shield of CA/BCBS BlueCard Network (Tier 2 Network), but you must receive Prime Utilization Review (UR) authorization. To do so, you or your physician should call Prime Customer Service at 877-234-5227 for assistance with this process. Family Practice, General Practitioner, OB/GYN, General Pediatrician and Internal Medicine are considered PCP’s. Be ready to provide the PCP’s name, address, and phone number when you call Customer Service. Please remember that the Tier 2 copay is considerably more than the copay for Tier 1.

When should I consider a Tier 2 PCP?

Some of our employees and their dependents live in remote areas and/or markets where there are a limited number of Primary Care Providers. In those instances, you may need to select a Tier 2 Provider. Please contact Prime Customer Service at 877-234-5227 to help you explore options that work best for you and your family.

Am I required to see my PCP before I can see a Tier 1 Specialist?

In some cases, yes. As with most plans, your PCP must refer you to a Specialist to ensure quality and coordination of care. Making it easy for our members, our plan doesn’t require an authorization to be obtained before seeing a Tier 1 specialist for your first office visit. If you’re your PCP has not referred you to see a Tier 1 specialist, please check with the specialist office if they require a referral from your PCP prior to your appointment. Most specialists require a referral from a PCP. The specialist will determine the course of treatment, if any, during your first office visit then submit to Prime UM for prior authorization. We suggest waiting to schedule the second appointment or to begin treatment until you receive the prior authorization in the mail. Unauthorized services may become your financial responsibility.

Can I continue to take my children to the same Tier 2 Network Pediatrician?

Yes. Your family can continue to see your general pediatrician for all primary care office visits if he/she is part of the Tier 2 Blue Shield of CA/BCBS BlueCard Network. Pediatric Specialists and non-preventive care testing require a referral from your general pediatrician and prior authorization from Prime UM. If your pediatrician’s office needs clarification, please have them call the number on the back of your ID card. The office is not required to contact Blue Shield for UR approval or plan direction.

Who should I contact to change my PCP?

Change your PCP by contacting Prime Customer Service at 877-234-5227. Please have you’re your PCP’s first and last name and office address when you call.

Will I pay a higher copay if I designate a Tier 2 PCP?

Yes. The Tier 2 copay listed on your medical ID card will apply.

How should my provider notify Prime UM of my referral? How long will it take Prime to approve or deny my referral?

Non-urgent referrals are generally processed within 7 – 10 business days and urgent referrals within 72 hours. For the status of a referral, please contact Prime Customer Service at 877-234-5227 or provider offices can log into the PAS (Prior Authorization System) referral system. The referring provider can sign up for the online automated PAS tool. PAS provides expedited referral turn-around times – nearly 60% of those received are auto adjudicated and approved within seconds of submission. To obtain a user ID and password, provider offices may send a request to EHP@primehealthcare.com.  Referral requests can also be faxed to Prime UM at 909-235-4414.

Where can I find a list of covered services that can be performed in my doctor’s office without prior authorization?

The list is available at www.primehealthcare.com/EHP or members may contact Prime Customer Service at 877-234-5227 for a list of approved procedures performed in the provider’s office, not subject to the referral and prior authorization process. You may also request this information by emailing EHP@primehealthcare.com.

Does my PCP need to request prior authorization for lab tests associated with my annual preventative wellness exam?

No. Prior authorization is not required for routine annual preventative care, including mammography (3D mammography requires authorization), colonoscopy, annual physical, and preventive lab services, which are covered at 100%. Non-preventative services require a referral and prior authorization through Prime UM. A list of services that do not need prior authorization can be found on our website at www.primehealthcare.com/EHP.

Plan Benefits

How much will I pay for inpatient and outpatient care received at a Tier 1 Prime Healthcare Facility?

No charge for covered benefits! The Prime Healthcare EPO plan is one of the best in the nation with the lowest cost to members. The Prime EPO Plan pays 100% of charges for most inpatient and outpatient hospital-based services received at a Prime Facility! This means little to no out of pocket cost to you.

What if my provider wants me to receive services at a Non-Prime Facility?

As a Prime EPO member, you have the right to request care at your preferred Prime facility. Receiving services at a Prime facility will ensure you have covered benefits and pay the least out of pocket expense. Providers may not be aware of your plan benefits and that it is to your advantage to receive services at a Prime facility because you will have little or no cost for these services. Discuss this with your provider if you are ever referred outside of the Prime Network for care. Prime Customer Service can aid in finding services within the Tier 1 Network: 877-234-5227.

How can I protect myself from surprise bills when I receive care from a non-Prime facility or provider?

We work to protect our members, and it’s your right to ensure that your providers get appropriate Prime UM prior authorization for your care before receiving services so that you have limited to no financial responsibilities. To protect yourself from surprise bills, we encourage you to notify your treating provider and non-Prime facility that prior authorization is required for any services outside the Prime Tier 1 network or at a non-Prime facility. If not, the services may not be paid.

My home is far from the closest Prime Healthcare Network facility. Do I have to travel to a Tier 1 Prime Healthcare facility, or can I use a Tier 2 facility closer to my home?

Your health plan benefits are based on the Prime facility where you are employed. Using the Prime Network will provide the least cost to our members. However, in the event of an emergency, always go to the nearest hospital. For after-hours, non-life-threatening situations, you may seek care at an Urgent Care with either a Tier 1 Prime Healthcare Network Provider or Tier 2 Provider.

What if I am out of town and become injured or sick?

As a Prime member, you can receive care at any Prime facility across the nation. If your situation is an emergency, please dial 911 or go to the nearest hospital. If it is not a life-threatening emergency, call Prime Customer Service at 877-234-5227. This number is listed on the back of your Medical ID card. A Customer Service representative will assist you with locating a contracted provider to minimize the out-of-pocket costs to you.  You can also locate Tier 1 Network providers and facilities at www.primehealthcare.com/EHP.

My dependent child lives outside of the Tier 1 Prime Healthcare Network service area. Is she still covered?

Employees with dependent(s) residing out of the Prime Healthcare service area should contact local HR and provide proof of residence. Appropriate proof includes: college acceptance letter dated within the last 12 months, state driver’s license, Student ID with the school name shown, last quarter or semester report card with school’s name or address listed, court documentation showing residence of children or other creditable proof of residence. Prime UM will provide authorization to access a Tier 2 PCP for the calendar year.

I have concerns regarding my privacy if I receive care at a Prime facility. What can be done to ease my concerns?

Every patient has the right to privacy. No matter where an employee works in the hospital, he/she must be aware and understand that all patients, including employees who are patients, have a right to privacy. This right is guaranteed under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

As a patient in the hospital, you have the right to control who will see and use your protected health information. This means that communications with or about your health information, including whether you are even a patient, will be private and limited to those who need the information for your treatment, payment, and healthcare operations. Prime Healthcare has a zero-tolerance policy regarding HIPAA violations.

Benefit*

What is the 1.5 Benefit?

The 1.5 Benefit was created to ensure that you and your covered dependents have access to comprehensive medical care at minimal out of pocket costs when available. If a Tier 1 Prime Facility or Tier 1 Prime Provider is not available in the Prime Network within a predetermined geographical distance (located in your benefits guide) of the Prime hospital/facility where you are employed, you and your covered dependents may be eligible for the 1.5 Benefit with Prime UM authorization. This means the applicable copay, coinsurance, or deductible would be the same as if you were receiving services at a Tier 1 facility or provider.

When does the 1.5 Benefit apply?

The 1.5 Benefit would apply when a service is unavailable in the Tier 1 Prime Healthcare Network within a predetermined geographical distance (located in your benefits guide) of the Prime hospital/facility at which a member is employed. Prime UM must provide approval for the 1.5 Benefit to apply. If approved for the 1.5 Benefit, the member’s out of pocket cost is based on the Tier 1 costs, instead of the higher amounts listed in Tier 2.

What if a service is not available in the Prime Tier 1 Network?

Prime UM will review each referral during the utilization determination process. If the service requested is determined unavailable within the Tier 1 Prime Healthcare Network, the member will be directed to a contracted Tier 2 Provider. The UR authorization will reflect approval of the 1.5 Benefit, and you will receive that authorization in the mail.

What if the care I need is not offered at a Tier 1 Prime Healthcare Facility?

Prime UM will arrange services with a contracted Tier 2 Facility once the referral is received and approved. We will make every effort to make this process as seamless as possible. You will receive an authorization in the mail.

To receive the 1.5 Benefit, do my provider or I need to request this benefit?

No. Prime UM will review referral requests and make this determination. If it is determined that the 1.5 Benefit applies, this will be noted on the authorization that is sent to the provider and mailed to the member. It is not the member’s or provider’s responsibility to request this level of coverage at the time of referral.

If my child needs emergency care and I choose to go to the nearest hospital, will the 1.5 benefit apply?

Always go to the nearest emergency room for medical emergencies. If a member is taken by ambulance to the emergency room, 1.5 benefits may apply. Keep in mind that Prime hospital emergency departments can provide emergency medical services for all pediatric patients. If transferred to another facility for admission or higher level of care, the emergency department will facilitate the transfer to ensure that quality of care is received. All emergency departments and emergency physicians are qualified to care for pediatric patients. 

If a member elects to go to a non-network hospital emergency room because of personal preference, then Tier 2 out of pocket costs will apply and may be subject to additional costs, above the usual and customary billed amount.

Benefit Options for Eligible Members and Dependents: MERP and Medicare

Is there any benefit if I enroll in my spouse’s medical plan and opt out of the Prime Healthcare plan?

Absolutely! If a member chooses to receive medical benefits under his/her spouse’s qualified medical plan or a separate employer plan, and waives medical coverage through Prime Healthcare, you may be eligible to enroll in MERP. This tremendous benefit provides payment of the out-of-pocket deductible, coinsurance, and copays. Please visit Human Resources for additional details and enrollment information. MERP is a valuable benefit provided at zero cost to you!

If I enroll in MERP, who is paying for my deductible, coinsurance, and copays?

Prime Healthcare pays almost 100% of your eligible medical expenses through the MERP program. MERP is an actual insurance policy that allows employers, such as Prime Healthcare, to pay the eligible out-of-pocket costs for employees and/or eligible dependents who have coverage through another plan.

If I receive a hospital bill, will MERP pay the entire cost?

Plans are restricted from charging individuals and families more than a limit determined by the Patient Protection and Affordable Care Act. Therefore, member costs should not exceed this maximum amount. The limit for 2022 is $9,100 per Individual or $18,200 for a family (two or more). Prime will pay up to this limit.

How and when can I learn more about Medicare options?

Medicare is a federal health insurance program for people who are 65 or older. If you, your spouse or dependent is eligible for Medicare, it is helpful to consider all options before making your health insurance elections during your New Hire Enrollment or Prime’s Open Enrollment. The next Medicare Open Enrollment/Annual Election Period is from October 15 through December 7, during which time you may be eligible to sign up for a Medicare Advantage plan, switch from one Medicare Advantage plan to another, or drop your plan and return to Original Medicare (Part A and Part B). To learn more about Medicare, call 1-800-MEDICARE or visit https://www.medicare.gov/.

Can I still cover my spouse on a Prime Healthcare plan if he or she already has coverage through a retiree medical plan and is eligible for Medicare?

Yes, but reviewing the options that are best for you and your family is important. A spouse with a retiree medical plan or who is Medicare eligible still meets the definition of an eligible dependent to participate in the Prime Healthcare medical plan. Medicare or a retiree supplement plan is not considered a qualified employer sponsored plan. We encourage our members to take advantage of the annual Medicare Open Enrollment period to learn about the potential savings and network that Medicare offers.

Referrals and Authorizations

What is the difference between a referral and an authorization?

A referral is the request the provider/physician submits to Prime UM as notification when referring a member for a higher level of care.

An authorization is an approval for the services requested from a referral. An authorization is often needed by providers or facilities to provide services to a member.

Who issues a referral and who issues an authorization?

A referral is issued by the physician/provider who is requesting further care for the member. Referral requests can be faxed by the physician/provider office to Prime UM at 909-235-4414 or via the PAS tool.

An authorization for Prime members is an approval given by Prime UM.

  • For certain services, a referral is all that is needed
  • For other services, such as Specialty care, a referral from the provider and a prior authorization from Prime UM is needed.
  • Referrals are often sent by providers to Prime UM for review and authorization. Prime UM will issue an authorization based on its review.
  • As a reminder, Prime UM handles all authorizations for services at non-Prime hospitals. The Blue Shield of CA/BCBS BlueCard Network cannot issue an authorization, so please make sure all your care is authorized through Prime.

Do I need a referral to access a Tier 2 facility for services?

Yes. Remember, if you obtain services through a Non-Prime Healthcare Network facility there will be no benefit coverage for the service unless prior authorization is obtained from Prime UM and the financial responsibility may be directed to the member. Prime wants to protect members from financial responsibility, so please make sure you obtain prior authorization for any Tier 2 service or provider.

How long will it take to get an authorization?

Non-urgent referrals are generally processed within 7-10 business days and urgent referrals within 72 hours. Many authorizations are now instantly and automatically approved. Prime Healthcare has built an automated platform (Prime Authorization System – PAS) for referral requests. More than 60% of specialty referrals are automatically approved with average turnaround times of two to three days for urgent authorizations and seven days for routine authorizations.

The PAS Tool is available for all physicians/providers to automate the referral process, and access can be provided by emailing EHP@primehealthcare.com. Referral requests can also be faxed to Prime UM at 909-235-4414.

Why am I being redirected to a provider within the Tier 1 Provider Network?

When your PCP or Specialist submits a request for authorization and it is determined by Prime UM that a Tier 1 Provider is available and can provide requested services, they will redirect members to that provider. Remember, services that are provided withing the Tier 1 Network provides benefits at a lower out of pocket to you!

What should I do if the Provider that I was referred to can’t see me, and another provider within the same office can see me? Can I see that Provider without notifying Prime UM?

In some cases, not all the physicians located within a provider’s office are part of the Tier 1 Provider Network. To avoid becoming financially responsible for services, please be sure to check that the provider is part of the Tier 1 Network. By calling Prime Customer Service at 877-234-5227 and notifying Prime UM, they will modify your authorization to redirect you to this provider within that office or can locate another provider that can see you within network.

If I am pregnant and prefer to deliver in a Tier 2 facility, do I need to obtain a referral and prior authorization?

Yes. Before using a Non-Prime Healthcare provider or facility, your PCP or provider must submit a referral request to Prime UM for maternity care and labor and delivery. Prime UM will review and can issue an authorization. Please remember that prior authorization is needed. Tier 2 rates and member responsibility may apply. Keep in mind that these costs may be significantly greater than Tier 1 rates, which may be little to no cost to you.

I have cancer and the Tier 1 Prime Healthcare Network near me does not have a cancer center. What should I do?

We want to ensure you have access to quality care. If you require a service that is not available near you within the Tier 1 Prime Healthcare Network, Prime UM will coordinate care through the Tier 2 Network. Your PCP should submit a referral to Prime UM, including CPT and diagnosis codes.

If I access an Urgent Care Center outside of the Tier 1 Prime Healthcare Network and lab work is required, will I need to return to a Prime facility for the lab work?

No. A member is not expected to travel back to the facility of employment for lab work during an Urgent Care visit. Be sure the Urgent Care center is within the Tier 2 Network prior to obtaining services. Urgent Care Centers within the Tier 2 network often incur less cost to members than if they seek services outside of our network. It’s a good idea to locate an in-network Urgent Care Center prior to needing one!

What labs and in-office procedures require Prime prior authorization?

Providers may reference the Prime approved labs and procedures that do not require Prime prior authorization on the approved procedures and labs list, available at www.primehealthcare.com/ehp. Examples of approved services include X-rays at the Orthopedic Surgeon’s office or urinalysis at the OB/GYN office. All labs and procedures not listed in the SPD as an approved service will require prior authorization from Prime UM.

What services require a referral or prior authorization from Prime UM for PCP and Specialist care?

For detailed plan information, please refer to the Summary Plan Description (SPD). The following chart provides examples of when you need a referral or authorization:
RequiredTier 1
Prime Employed		Tier 1 Network
Prime Healthcare
Tier 2 Network
Blue Shield of CA/BCBS
BlueCard
ServiceReferralAuthorizationReferralAuthorizationReferralAuthorization
Primary Care Office Visit**
General Practice, Family Practice,
OB/GYN, Internal Medicine
N/ANoN/ANoN/AYes3
Pediatrician Office VisitN/ANoN/ANoN/ANo
Specialist Office Visit1
Initial Visit/Consult and
Follow up visits
NoNoYesNo2YesYes3
PCP Lab Work
In-Office Preventive/Routine
NoNoN/ANoN/ANo4
PCP Lab Work
In-Office Non-Preventive
NoNoN/AYesN/AYes
Auto-Approved Services
Visit
www.primehealthcare.com/EHP
for a list of these services		NoNoNoNoNo4No4

  1. Specialist Office Visits

Initial consults with Tier 1 specialists require a PCP referral, but do not require authorization or Prime UM Review.

  1. Tier 1 Prior-Authorization Not Required

Office visits (evaluation and management codes) *
Auto-approved codes (www.primehealthcare.com/EHP)*
US Prevention Task Force Preventive screening services (www.uspreventiveservicestaskforce.org/uspstf)
Facility-based services provided at a Prime facility*
*  All Other specialty services not listed above will require Prior Authorization.
*  Please verify benefits & review for services with a limited benefit.

  1. Tier 2 Authorization

If authorization to a Tier 2 provider is approved and Tier 1.5 benefits are applied:

  • Three follow-up visits are approved within 365 days following the initial approved authorization date.
  • A new authorization is required for follow-up visits after 365 days of initial approved authorization.
  • All other services require prior authorization for each follow-up visit.
  • Benefits may differ based on location with some locations not requiring authorization for Tier 2 PCP visits.
  1. Tier 2 Lab Work

All labs should be sent to a Prime facility or Prime-contracted LabCorp. All other labs require an authorization.

What services require a referral or prior authorization from Prime UM for Facility Services?

For detailed plan information, please refer to the Summary Plan Description (SPD). The following chart provides examples of when you need a referral or authorization:

RequiredPrime Owned Hospitals/FacilitiesNon-Prime Facilities
ServicePCP Order or
Prescription
ReferralAuthorizationPCP Order or
Prescription
ReferralReferral
Imaging: MRI / CT / MRA/
PET scan / DEXA / Hospital Imaging		YesNoNoYesYesYes
Inpatient HospitalizationYesNoNoYesYesYes1
Outpatient SurgeryYesNoNoYesYesYes
Bariatric Services YesYesYesYesYesYes
Sleep StudiesYesYesNoYesYesYes
Emergency Room ServicesN/ANoNo2N/ANoNo2
Urgent CareN/ANoNo3N/ANoNo3
Labs4YesNoNoYesYesYes
Auto-Approved Services
Visit
www.primehealthcare.com/EHP
for a list of these services		YesNoNoYesYesYes

  1. Inpatient Hospitalization: Prime UM must be notified, and authorization is required for post stabilization care and inpatient hospitalization.
  2. Emergency Department Services: are to be provided at a Prime facility whenever possible, if rendered at a non-Prime facility Tier 2 rates may apply.
  3. Urgent Care: should be provided at a Prime facility ER or contracted urgent care facility whenever possible, if rendered at a non-Prime facility Tier 2 rates may apply.
  4. Labs: Any Lab Services should be sent to Prime Facility Lab or Prime Contracted Lab Corp

How to read your Referral?

Click here for the instructions.

The Prime Value Plan

If I am a Prime Value Plan member, will my referrals go through the Prime UM Department?

Yes. The referral and prior authorization process for all Prime Healthcare medical plans is handled through the Prime UM department.

Am I required to stay within the Tier 1 Prime Healthcare Network?

No. You may choose to use Tier 1 or Tier 2 providers for your care. When your PCP sends a referral request to Prime UM, if a required service is available in the Tier 1 Prime Healthcare Network, members will be notified that a lower cost option in Tier 1 is available.

Will I need a referral or authorization when seeking services in Tier 1 or Tier 2?

Yes. A referral from your PCP would be required in the same instances as the Prime EPO plan for specialty services and care. Please refer to the Summary Plan Description (SPD) for details. Remember, staying within the Prime Network (Tier 1) will result in less out-of-pocket costs to you.

Medical Emergencies

If I need to go to the Emergency Room, can I go to any hospital?

In an emergency, members should always go to the nearest hospital. Out-of-pocket payments are based on whether the facility is contracted as a Tier 1 or Tier 2 Provider, or out-of-network.

What if I am taken to a non-Prime Hospital Emergency Department and need to be admitted?

Prime UM reviews all cases to help coordinate your care and ensure you receive the care you need. If you are ever hospitalized, the hospital and provider must contact Prime UM to receive authorization, or the care you receive may not be covered. Once it is determined that you are clinically stable, we can help you return to the Prime Healthcare Network. Remember, staying within the Prime Healthcare Network this means lower out of pocket costs to you. Prime UM clinical care associates are available 24 hours a day, 7 days a week. The number can be found on the back of your medical ID card, or you can call Prime Customer Service at 877-234-5227 for assistance.

What if I am out of town and become injured or sick?

As a Prime member, you can receive care at any Prime facility across the nation. If your situation is an emergency, please dial 911 or go to the nearest hospital. If it is not a life-threatening emergency, call Prime Customer Service at 877-234-5227. This number is listed on the back of your Medical ID card. A Customer Service representative will assist you with locating a contracted provider to minimize the out-of-pocket costs to you.  You can also locate Tier 1 Network providers and facilities at www.primehealthcare.com/EHP.

Claims and Explanation of Benefits (EOB)

What should I do when I get an EOB and it says I have a responsibility to pay?

Please remember that an EOB is not a bill, it is an explanation of how your benefits were applied to your claim. Please contact Prime Customer Service at 877-234-5227.

Why wasn’t my claim paid?

Each situation is unique and should be discussed with a Claims team from Keenan Customer Service at 888-773-7218.

Why was I sent to collections?

Prime Healthcare does not send members to collections. Providers may send members a bill and subsequently to collections if not resolved. Please reach out to your Provider directly, or the organization listed on the bill you received.

Please be sure to always open correspondence from Keenan and review your Explanation of Benefits (EOB). If the denial was issued in error, it can be corrected before the Provider sends to collections. Prime does not want any of our members to be directly billed by Providers for services that were approved and authorized by Prime UM or already paid by Prime. If this occurs, we will work to protect you and resolve this. Please call Prime Customer Service at 877-234-5227 and select the “Claims” prompt for assistance.

How to read my EOB?

Click here for the instructions.

Balance Billing

What is Balance Billing?

When providers bill a patient for the difference between the amount they charge and the amount that the patient’s insurance pays (excluding your deductible, co-pay and co-insurance).

Note: Balance Bills to our members are not bills from Prime/Keenan. Members receive bills from providers and facilities outside of Tier1 Network.

What are the top reasons for balance billing?

1. Receive services from a doctor, hospital, or other health care provider who does not have a contract or relationship with Prime (not part of Prime’s provider network).

2. Receive services that are not covered by Prime benefit plan, even if you’re getting those services from a provider that has a contract or relationship with Prime.

3. Receive services without required referral and prior authorization approval.

4. Receive services from out-of-network providers.

How to prevent from being Balance Billed?

  • Understand your SPD, including but not limited to covered benefit, required prior authorization or required referral, member costs for non-Prime utilization, exclusions and limitations, and member responsible cost share.
  • Use of only Prime facilities and Prime Tier 1 Provider network to protect you from higher cost care. Use the current Provider Directory available online. Prime UM/UR assists our members by redirecting the referral to Prime Tier 1 providers when available and appropriate.
  • If services are provided by Tier 2 facilities, Tier 2 costs are often significantly higher than Tier 1 costs.
  • Obtain prior authorization approval (see Referrals and Authorization section for additional details) before receiving the service, otherwise the service cannot be covered by Prime and providers may seek payment directly from members.

Note: Prime works to protect our members from the bills from outside providers and facilities, but if prior authorization or required referrals are not obtained, then Prime is unable to prevent these providers from billing our members. We will work to support and defend our members.

General Questions

If I need to make changes to my benefit elections, when can I make changes?

A member may make changes during Open Enrollment, if there is a qualifying event, or if he/she qualifies for a “special enrollment.” If a member qualifies for a mid-year benefit change, proof of the change must be provided to HR within 31 days. Some examples of qualifying events include change in legal marital status, including marriage, divorce, legal separation, annulment, and death of a spouse; change in number of dependents; change in employment status that affects benefit eligibility, and much more. Please check with your local HR Department for a complete list.

Is there a Customer Service Department that can help me with questions?

Yes! Prime Healthcare has a dedicated Customer Service Call Center designed to ensure prompt service. A phone prompt has been added to ensure that all urgent medical matters are addressed in real time.

The Prime Customer Service number is 877-234-5227. A dedicated email has been established for members to address all non-HIPAA questions: EHP@primehealthcare.com. Messages are responded to Monday through Friday, typically within 24 hours

Is Keenan Customer Service the same as Prime Customer Service?

No. They are two separate entities.

Keenan Customer Service (888-773-7218) oversees member eligibility, issues benefit verification for Providers, claims and appeals.

Prime Customer Service (877-234-5227) provides the status of referral and prior authorizations, facilitates urgent requests for authorization, oversees inpatient admissions, discharge planning, transfers, referral appeals, retroactive referral requests, provider finder, claim issues and prescription appeals.

How can I obtain a replacement or duplicate copy of my medical ID card?

Contact Keenan Customer service at 888-773-7218 or simply logon to www.keenan.com/benefits.  You will need to establish an on-line account prior to utilizing this feature.

I have questions about my prescription coverage. Who I contact for help?

Please contact Express Scripts at 866-718-7955 or view your account online at www.express-scripts.com.

Who can I contact for assistance with my medical benefits at Prime Healthcare?

For: Utilization Review/Prior Authorization, Referrals and Referral Status, Provider Finder call Prime Customer Service: 877-234-5227

For: Benefits/ Eligibility/ Claims/ Appeals/ Provider Finder call Keenan Customer Service: 888-773-7218. www.keenan.com/benefits

Prime EHP Email Address: Any non-HIPAA related questions, send an email to EHP@primehealthcare.com

Prime UM General Fax (Referrals): 909-235-4414, Alternate Fax1: 909-235-4404, Alternate Fax2: 909-235-4427

Prime UM Concurrent Review/Inpatient Fax: 833-729-5928

EHP Prime Healthcare Website: www.primehealthcare.com/EHP

Tier1 Provider Finder: https://ehp.primehealthcare.com/find-a-provider/