File a Grievance/ Appeal

How to Submit a Grievance

We want to hear your concerns about the quality of health care services you receive. If you are not happy, are having problems or have questions about the service or care given to you, let your doctor know. Your doctor may be able to help you or answer your questions.
If you are still not happy, you may report your problem — or file a grievance — with Prime Healthcare.
To file a grievance call Prime Customer Service at 877-234-5227

How to Submit an Appeal
Click here to download the form

Submit forms completed with all information

By Mail

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

Phone: 888-773-7218
Fax: 310-533-5755

How to submit an appeal:

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.

Important Information About Your Appeal Rights

What if I need help understanding this denial?

Contact customer service at the number located on the front of this notice or on the back of your ID card if you need assistance understanding this notice or the decision of payment, service or coverage.

What if I don’t agree with this decision?

You have the right to appeal a decision to deny payment for a claim, service or coverage, in whole or in part.

Who may file an appeal?

You or someone you name to act for you (your authorized representative) may file an appeal. Contact customer service to request the approved form to designate your authorized representative in writing. You must use the approved Keenan form in order for us to speak to your authorized representative.

How do I file an appeal?

Send the appeal in writing that identifies the claim decision to deny payment, service or coverage, and any supporting documentation to:

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

Phone: 888-773-7218
Fax: 310-533-5755

You must submit an appeal within 180 days of the date of this notice. Failure to submit an appeal within the 180-day time period will result in your appeal being denied.

See also the “Other resources to help you” section of this page for assistance filing a request for an appeal.

Can I provide additional information about my claim?

Yes, you may supply additional information with your appeal or by contacting customer service by phone or mail.

Can I request copies of information relevant to my claim?

Yes, you may request copies (free of charge) by contacting customer service. If you think a coding error may have caused this claim to be denied, you have the right to request billing and diagnosis codes be sent to you. You can request copies of this information by contacting customer service.

What happens after I submit an appeal?

If you appeal, the decision will be reviewed, and you will be provided with a written determination. If the payment, coverage, or service requested continues to be denied or you do not receive a timely decision, you may submit a second appeal within 60 days of the notice of denial.

Within four months of the decision on your second appeal, you may be able to request an external review of your claim by an independent third party who will review the denial and issue a final decision. You must exhaust two levels of appeals before you can request an external review. Contact customer service to find out if you are eligible for an independent third-party review. Following this appeals process, you may have the right to bring a civil action under section 502(a) of the Employee Retirement Income Security Act (ERISA), depending on the terms of the Plan documents, if brought within two years after the Claimant’s initial claim or within six months from the date of the final claim decision on appeal, whichever comes first, or if shorter, the date specified in the Plan documents. In some circumstances, the Plan documents may require binding and confidential arbitration instead of filing a civil action in court.

Other resources to help you: For questions about your rights, this notice, or for assistance, you can contact: Employee Benefits Security Administration at 1-866-444-EBSA (3272).