Why Choose Prime?
Prime separates from our competitors offering the client the best solutions for challenging needs.
What if networks could be more customized?
Prime Health Services has evolved over the past 15 years into one of the largest and fastest growing comprehensive, national Preferred Provider Organizations and Cost Containment companies in America. Prime Health has over 700,000 providers and facilities in all 50 states and the District of Columbia forming the Prime Health National Delivery System for workers’ compensation, group health, corrections, and liability (general and auto). In addition, Prime Health Services offers other services such as: Prime Metrics, PrimeRX (an industry unique pharmacy management solution), and Prime IME Solutions (a national IME service).
What sets us apart from our competitors?
Prime Health is a privately held company, with the original founder of the company leading the senior management team. As a result, all of our partners and clients are treated with a level of service and consideration that just isn’t that common in today’s business world of large corporation and venture capitalist ownership. Additional differentiators from our competitors include:
High percentage of directly contracted providers
Provider disputes averaging under 1% nationally
Provider retention averages over 99%.
What can Prime Health Services offer you?
At Prime Health Services, we understand that as important as the bottom line results are, there are many more factors that define a good and valued service partner. For our clients, this means we:
Maximize penetration and savings while offering highly competitive network access rates.
Quickly and efficiently create and implement the best service model.
Provide for a near instant repricing capability, utilizing a proprietary technology built on the XML Soap platform.
“Turn on a dime” to make any changes that our clients need to improve the service delivery process.
Customize the network to meet our customers’ unique geographic or provider specialty needs through our unrivaled out of network provider nomination and credentialing process.
Notices and Updates
Based on the disclosures required of group health plans and health insurance issuers in the No Surprises Act, Prime Health will provide the in-network providers’ negotiated rates.
Providing these deliverables allows transparency within tasks being asked of our clients and our clients’ clients.
At Prime Health, our provider contracts are evergreen and we can track when a provider (NPI) status is disabled or a contract (TIN) is termed. We also track dates on contracts and discounts when they are added/changed.
Prime Health uses commercially reasonable efforts to maintain accurate provider directories, which are regularly updated and verified at least every 90 days. Prime Health will respond, within one business day, to individuals who inquire about the network status of a provider or facility.
To aid in this initiative, with the use of technology, Prime Health is working with industry leaders in the provider data collection and verification space.
Beginning July 1, 2022, health care providers will need to:
• Submit the CMS-1500 form. Electronic submission through an XML submission partner is strongly encouraged, though not required. When mandatory submission of the CMS-1500 form begins, use of current medical billing/reports including Doctor’s Initial Report (Form C-4) and Doctor’s Progress Report (Form C-4.2) will be discontinued.
• Prominently report the injured worker’s temporary impairment percentage, work status and the causal relationship of the injury at the top of the CMS-1500 form medical narrative.
Between now and July 1, 2022 health care providers are urged to review their processes to understand how these changes will affect them. The Board will continue to post periodic updates to the website based on feedback and questions received from stakeholders.
More information can be found at http://www.wcb.ny.gov/CMS-1500/
Prime Health works hard to remain in compliance with the various requirements of our governments and court systems.
Take a Tour of the Markets We Serve
We have a dedicated repricing and reconsideration department with providers & partner networks diligently working to resolve claim disputes.
The goal at Prime Health is to have all clean claims with no disputes and no reimbursement issues. However, part of the nature of a PPO network is addressing, an industry average of 3% claim disputes. Prime Health is proud to have an average of 1.2% claim disputes. Clients may submit disputes via email email@example.com, or via fax to 615-329-4411. Clients with questions may also call our Claims Resolution Department at 1-866-348-3887.
Prime Health is dedicated to the fast response of disputed claims which applied a Prime Health discount. Our average turnaround for dispute resolution is 3 to 5 business days. Upon resolution of the claim dispute, clients will be advised in writing an explanation of the resolution and instructions if further reconsideration is necessary.
Common Reasons for a claim dispute to arise
- The EOB/EOR (Explanation of Benefits / Review), does not properly list Prime Health or our Partner Network
- Provider does not recognize their contract with Prime Health or our Partner Network
- An error in repricing the claim occurs with Prime Health or Client
Prime Health request that the following information be included when submitting a dispute:
- Provider name / or patient name in the subject line
- A copy of the EOB/EOR and corresponding claim from being disputed
- Provide a brief explanation of the dispute, or the actual appeal letter
- Provide contact name and number of the person disputing