Member Appeal Process

To initiate a benefit or medical necessity appeal, Prominence Health Plan members must submit a request for an appeal in writing to Prominence Health Plan within 180 calendar days after receipt of your denial notice.

Prominence Health Plan will provide you with a written decision regarding your appeal no later than 30 calendar days after we receive your appeal.

If you are in a hospital or if you or your doctor believes that your health could be seriously harmed by waiting too long for a decision, you may request, orally or in writing, an Expedited or Urgent Care Appeal. We must give you a decision within 24-72 hours after we receive your appeal.

If you have exhausted the appeals process for an appeal based on a medical necessity denial which represents a cost of $500 or more, you may, at no cost to you, request an independent review. This independent review will be conducted by an external review organization certified and appointed by your state of residence:

State of Nevada
Office of Consumer Health Assistance

State of Texas
Office of Consumer Health Assistance

With your appeal please provide any information or documents relevant to your appeal. All appeals are reviewed by the Plan Medical Director or by a specialist in the same or similar specialty as the requesting Practitioner. You can obtain a copy of actual benefit provisions, guidelines, or protocol on which the denial decision was based upon request.

Guidelines and protocols are nationally recognized Medical Management review criteria that are objective and based on medical evidence, in order to make impartial fair and consistent decisions.

If you fail to appeal a denial within the 180-calendar day time frame, you lose your right to appeal.

The Prominence Health Plan Appeals Specialist can be reached by email at [email protected] You can also contact Customer Service for more information.