Reviews

This profile includes reviews for Prairie States Enterprises, Inc.'s headquarters and its corporate-owned locations. To view all corporate locations, see Find Local Branches.

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  Prairie States Enterprises, Inc.

  615 Pennsylvania Ave Sheboygan, WI 53081-4642

  
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  Prairie States Enterprises, Inc.

  PO Box 23 Sheboygan, WI 53082-0023

  

Review Details

• Review fromJamie D

  Date: 12/03/2024

  1 star
  Prairie States Insurance is denying payment for my daughter's orthopedic care. They indicate that the reason for denial is that they didn't know how the incident occurred. Yet, if they read the medical information, they would have seen this info. In addition to this, they allege that they mailed a form for me to complete regarding this, but it wasn't returned. I was ill with sepsis at the time and unable to view mail. However, my children do not recall seeing any letter regarding this, and upon regaining my cognitive ability and viewing mail collected while ill, I did not have any mail from Prairie States. I do not believe any such form was sent. The company is unable to prove this occurred. There was never a phone call from them or e-mail regarding this nor did they contact the provider regarding why they were denying the claim. The provider and I were both dumbfounded regarding why it wasn't covered. I paid my premiums, and they took the money, but when time to pay bills, they refuse to do so. I am appealing this and also contacting the Office of the Commissioner Of Insurance and Attorney General in Wisconsin regarding this.
  

• Review fromMichelle P

  Date: 01/03/2024

  1 star

  Michelle P

  Date: 01/03/2024

  Honestly, I have had the worst experience with this company. They have so many loop holes and restrictions and cannot communicate appropriately at all. They are impossible to get a hold of. They denied a payment on a surgery that they already pre-authorized, because my doctors office didnt put the right code. When I asked which code was needed, they said they couldnt tell me or my doctors office that. The office then had to jump through all of these loop holes just to get paid for a surgery that was performed 11months ago. Now they are denying authorization for a necessary surgery for my daughter. The ENT asked them for a peer to peer to go over the reasons for why they denied it, and they denied that. Now we are having to go through an appeal process just to get the ENT a chance to have a peer to peer to possibly get authorization for the surgery. All while risking my daughter becoming deaf from chronic ear infections. DO NOT RECOMMEND.
  

  Prairie States Enterprises, Inc.

  Date: 01/05/2024

  Both of the members issues are related to a dependent.
  
  #1: PSE received a request for surgery, which was approved as medically necessary. Once the claims arrived to ***, were sent to network for reprocessing. This is so the claim can be reviewed and edited for appropriate amounts to be paid. For the service that was in Feb of 2023, the claim was not received from the surgery center until mid-August 2023 and was paid in mid-October. Upon review of the claim via the Pluto edit system (not PSE) they determined the billing of the surgeon and the facility did not match, were not appropriate, and edited the claim. The claim document sent to the member showing what was paid and not paid, explained to call ***** at ************, so they could direct them on any next steps and explain the situation.
  At this time, the facility has recently sent in a corrected claim which is currently being reviewed by the network for appropriate discounts to be rendered.
  
  #2: On the recent denial of a procedure, PSE received a request for surgery on 12/11/2023.The ** RN was not able to approve the request and sent the item to specialty medical review. Once sent, the ** RN also sent a letter to the ordering provider letting them know that an MD was reviewing the request and a peer to peer  ( Physician to Physician) call *** occur in the next few days. We also share the number listed in case they want a different number added to the peer to peer. During the review,the MD called for peer to peer on 12/13/2023 at 10:12 am CT, 12/13/2023 12:35 pm ** and on 12/18/2023 2:34 pm **. As no peer to peer call was returned within the timeframe of review, the MD reviewer was able to review the medical plan document and clinical information only. The result of this information was a denial as not medically necessary. This denial result was issued via a letter to the member and provider, including appeal rights, on 12/19/2023. The provider then called on 01/02/2024, about making a peer-to-peer call. At that time, since the denial was rendered, PSE advised that the time for a peer-to-peer has passed, and the decision is complete. The member and provider have a right to appeal, and we allow peer to peer conversations during the appeal review as well.  

  However,to rectify this situation, upon my direction, Prairie States will make an exception to the process and reopen and extend the peer-to-peer period.  We have the majority of the data to complete this process expeditiously and shall do so. 

  
  
  

  Prairie States Enterprises, Inc.

  Date: 01/05/2024

  
  Both of the members issues are related to a dependent

  #1: PSE received a request for surgery, which was approved as medically necessary. Once the claims arrived to ***, were sent to network for reprocessing. This is so the claim can be reviewed and edited for appropriate amounts to be paid. For the service that was in Feb of 2023, the claim was not received from the surgery center until mid-August 2023 and was paid in mid-October. Upon review of the claim via the Pluto edit system (not PSE) they determined the billing of the surgeon and the facility did not match, were not appropriate, and edited the claim. The claim document sent to the member showing what was paid and not paid, explained to call Pluto at ************, so they could direct them on any next steps and explain the situation.
  At this time, the facility has recently sent in a corrected claim which is currently being reviewed by the network for appropriate discounts to be rendered.
  
  #2: On the recent denial of a procedure, PSE received a request for surgery on 12/11/2023. The ** RN was not able to approve the request and sent the item to specialty medical review. Once sent, the ** RN also sent a letter to the ordering provider letting them know that an MD was reviewing the request and a peer to peer  ( Physician to Physician) call *** occur in the next few days. We also share the number listed in case they want a different number added to the peer to peer. During the review, the MD called for peer to peer on 12/13/2023 at 10:12 am CT, 12/13/2023 12:35 pm ** and on 12/18/2023 2:34 pm **. As no peer to peer call was returned within the timeframe of review, the MD reviewer was able to review the medical plan document and clinical information only. The result of this information was a denial as not medically necessary. This denial result was issued via a letter to the member and provider, including appeal rights, on 12/19/2023. The provider then called on 01/02/2024, about making a peer-to-peer call. At that time, since the denial was rendered, PSE advised that the time for a peer-to-peer has passed, and the decision is complete. The member and provider have a right to appeal, and we allow peer to peer conversations during the appeal review as well.  
  However, to rectify this situation, upon my direction, Prairie States will make an exception to the process and reopen and extend the peer-to-peer period.  We have the majority of the data to complete this process expeditiously and shall do so.