Claims Payment and Appeals Process
The following Internal Claims and Appeal procedures and definitions have been developed to ensure a timely and appropriate response to a member’s concerns. Prominence Administrative Services will take into account the clinical urgency of the situation as it relates to the timeliness of responding to Complaints and Appeals.
Prominence Administrative Services Customer Service can be reached at 800-455-4236, Monday through Friday from 6 am to 5 pm PT.
For purposes of these claims procedures, a claim is any request for Plan benefits. This page is a general overview of claims processes. For appeals procedures, claims submission and definitions, please review your employer benefit plan document.
Explanation of Benefits
Members will receive an Explanation of Benefits for all claims. 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 that provide similar coverage, the group health plan will coordinate benefit payments with the other company. Please consult your plan’s Summary Plan Description 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
To file a claim, a member must:
- Download Claim Form, or
- Request a claim form from the Subscriber’s employer or from Prominence Administrative Services within 20 days after charges are incurred, or as soon as reasonably possible. Prominence Administrative Services will send the claim form to the member within 15 days after receiving the request.
Completed claim forms and the original bills should be mailed to:
P.O. Box 981732
El Paso, TX 79998-1732
Electronic Payor ID: 88022
Claim forms and bills can also be faxed to 775-770-9363 or emailed to [email protected]
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 the group health plan from any further obligation. The group 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.
For more information about the claims process including what happens when a claim is denied and how to appeal a decision or resolve a complaint, visit the secure member portal and refer to your health plan documents for additional detail.