Making an Appeal

If you are not satisfied with an organization/coverage decision we made, you can appeal the decision. An appeal is a formal way of asking us to review and change an organization/coverage decision.

Appeals Process

1. To file an appeal, please contact the Plan by calling Member Services at 855-969-5882 (TTY: 711). You can also send your request to our Appeals Department by mail or fax at:
   • Prominence Health Plan
     Grievance and Appeals Department
     1510 Meadow Wood Lane
     Reno, NV 89502
     Phone: 855-969-5882
     Fax: 775-770-9004
2. We will review the decision we made to check that we followed all the rules properly.
3. Once we have completed our review we will send you our decision.
4. If we deny all or part of your Level 1 Appeal, you can proceed to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our Plan.
5. If you are not satisfied with the result of the Level 2 Appeal, you may be able to continue through several more levels of appeal.

For detailed instructions on the appeals process, please see the “What to do if you have a problem or complaint (coverage decisions, appeals, complaints)” section of your Evidence of Coverage. The Evidence of Coverage (EOC) is a comprehensive resource guide to your healthcare coverage and is considered a legal document.

Provider Payment Disputes (Claim Reconsideration)

A provider payment dispute is a formal request to review the reimbursement amount of a claim when the provider disagrees with the payment determination. These disputes do not involve medical necessity decisions or administrative denials, and a payment decision has already been made on the claim.

Submission Requirements:

• Requests must be submitted in writing.
• The dispute must be filed within 90 days of the original claim payment date.
• Include sufficient claim details to identify the claim, along with a clear explanation of why the payment amount is believed to be incorrect or requires adjustment.
• Attach any relevant supporting documentation, such as medical records, billing information or other evidence that supports the request.

Mailing Address:
Payment Disputes
1510 Meadow Wood Lane
Reno, NV 89502
Fax: 775-770-9004

Participating Provider Appeal

A participating provider may submit a written appeal to request reconsideration of a payment determination or to seek an exception based on specific circumstances.

Appeal Requirements:

• Appeals must be submitted in writing.
• Requests must be received within 90 days of the remittance advice date.
• Include the member’s identifying information.
• Provide the applicable dates of service.
• Clearly explain the reason for the appeal and why the payment determination should be reviewed or an exception considered.
• Submit all relevant medical records and any supporting documentation that substantiates the request.

Mailing Address:
Appeals and Grievances
1510 Meadow Wood Lane
Reno, NV 89502
Fax: 775-770-9004

Providing complete and accurate information helps ensure the Appeals and Grievances team can conduct a thorough review and issue a determination within 60 business days. Appeals that are incomplete or do not meet the submission requirements may experience processing delays.

Non-Participating Provider Appeal

If a claim is denied, either in whole or in part, a non-participating provider may request a review of the determination by submitting a written appeal. Appeals must be received within 65 days of the remittance advice date.

A completed and signed Waiver of Liability (WOL) form is required with all non-participating provider appeals. This form confirms that the member will not be held financially responsible for the services in question, regardless of the appeal outcome.

To facilitate a comprehensive review, the appeal should include:

• A copy of the remittance advice identifying the claim denial
• Relevant clinical records, when applicable
• Any additional supporting documentation that substantiates the request for reimbursement or reconsideration

Mailing Address:
Appeals and Grievances
1510 Meadow Wood Lane
Reno, NV 89502
Fax: 775-770-9004

Submission of complete and accurate documentation will help ensure the appeal is reviewed efficiently and without unnecessary delays.