Internal Claims and Appeals Procedures
The following Internal Claims and Appeal procedures and definitions have been developed to ensure a timely and appropriate response to a Member’s concerns. Additionally, Prominence Health Plan will take into account the clinical urgency of the situation as it relates to the timeliness of responding to Complaints and Appeals. Prominence Health Plan Customer Service is available between 8 a.m. and 5 p.m. To call Customer Service, refer to the phone number on the back of the member ID card or Contact Us.
For purposes of these claims procedures, a claim is any request for Plan benefits.
Explanation of Benefits
Health Maintenance Organizations (HMO) health plans to not require a member explanation of benefits. However, embers may receive an Explanation of Benefits for some claims if there is member responsibility. The Explanation of Benefits displays the amount billed, amount eligible for payment, any contractual discount and amount of member responsibility.
Coordination of Benefits
In cases when a Member is covered under two insurance contracts which provide similar coverage. Prominence HealthFirst will coordinate benefit payments with the other company. Prominence HealthFirst will pay its benefits if all State-approved guidelines are followed. Please consult your plan’s Evidence of Coverage for the Coordination of Benefit rule
Adverse Benefit Determination
An Adverse Benefit Determination eligible for “internal” claims and appeals processes includes, but is not limited to a denial, reduction, or termination of, or a failure to provide or make a payment (in whole or in part) for a benefit, including any such denial, reduction, termination, or failure to provide or make a payment.
How to File a Claim
In order to file a claim, a Member must:
- Either download a copy of the claim form; or
- Request a claim form from the Subscriber’s employer or from Prominence Health Plan within 20 days after charges are incurred, or as soon as reasonably possible. Prominence Health Plan will send the claim form to the Member within 15 days after receiving the request.
Prominence Health Plan will have the right, at its own expense, to physically examine any Member whose illness or injury is the basis of a claim. This may occur when and as often as Prominence Health Plan may reasonably require.
Where to Send a Claim
Completed claim forms and the original bills should be mailed to:
Prominence Health Plan
1510 Meadow Wood Lane
Reno, Nevada 89502
All benefits will be paid to the Member or with written direction to the provider of medical services. Any payment made under this option will completely discharge Prominence Health Plan from any further obligation. Prominence Health Plan reserves the right to allocate the Deductible amount to any eligible charges and to apportion the benefits to the Member and to any assignees. Such actions will be binding on the Member and on his assignees.
When a Claim is Denied
Every notice of an Adverse Benefit Determination, or denial of claim, will be set forth in a manner designed to be understood by the member, will be provided in writing or electronically, and will include all of the following information that pertains to the determination:
- A notice of Adverse Benefit Determination will include information sufficient to identify the claim involved, including the date of service, healthcare provider and claim amount (if applicable), and a statement notifying the claimant that they may request their diagnosis and treatment code(s) as well as the code’s corresponding meaning(s). Prominence HealthFirst will provide such codes and corresponding meanings as soon as practicable after receipt such requests. Requests for diagnosis and treatment code(s) and corresponding meaning(s) are merely information requests and will not trigger the start of an internal appeal or external review.
- The specific reason or reasons for the claim denial;
- Reference to the specific plan provisions upon which the determination is based;
- A statement that You may request access to, and copies of, all documents, records and all other information relevant to Your claim;
- If an internal rule, guideline, standard, protocol, or other similar criterion was relied upon in denying Your claim, a statement that a copy of such rule, etc., will be provided free of charge upon request;
- If the denial is based on a Medical Necessity or Experimental treatment or similar exclusion or limit, a statement that an explanation of the scientific or clinical judgment for the determination will be provided free of charge upon request;
- An explanation of the plan’s review procedures and the time limits applicable to such procedures, including a statement of Your right to bring civil action under Section 502(a) of ERISA following a denial on Appeal, and;
- In the case of a claim involving Urgent Care, a description of the expedited review process applicable to such claim.
Resolving Member Complaints or Claims
Prominence Health Plan will do its best to resolve any questions or concerns You may have on Your initial contact. If it needs more time to review or investigate Your concern, Prominence Health Plan will get back to You as soon as possible, but in any case within 30 calendar days for all non-Urgent Care claims. If You are not satisfied with the results of a coverage decision, You can begin the Internal Appeals procedure.
Internal Appeals of Denied Claims
An Appeal is defined as a Member’s request for Prominence Health Plan to change an Adverse Benefit Determination.
To learn more about how to file an appeal, visit Member Appeal Process
External Review of Denied Claims
If Prominence Health Plan has denied Your request for the provision of or payment for a health care service or course of treatment You may have a right to have our decision reviewed by independent health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment You requested by submitting a request for external review within four months after receipt of this notice to:
Nevada Office for Consumer Health Assistance (OCHA)
555 East Washington #4800
Las Vegas, NV 89101
Phone: 702-486-3587, 888-333-1597
Claims may be retroactively denied if eligibility updates confirm the member was not eligible at the time of service. Additional reasons may be secondary insurance coverage, worker’s compensation claims. To avoid retroactive denial of claims, ensure premiums are current and eligibility confirmed prior to receiving services.
Claim Grace Periods
For individuals not eligible to receive APTC, the 30-day period from the date Premium payment is due until it is considered delinquent. For an individual eligible to receive APTC, the three-month period from the date premium payment is due. Claims may be pended until payment is received.
During the Grace Period, coverage remains in effect. See plan Evidence of Coverage for additional information
If a member receives services from an out of network provider, they may be responsible for paying the difference between the billed charges and the plan’s allowable rate. The plan’s allowable rate is what the plan would have paid to an in-network provider.
If your coverage terminates from Prominence Health plan, and a refund of premium is due, please contact Prominence Health Plan Customer Service at the phone number on the back of the member ID card or Contact Us.
Drug Exception Process
For information about the drug exception process, visit the Pharmacy Services page.