How to bill Priority Health
General claim requirements
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All claims must be typed or electronically generated; Priority Health cannot accept hand-written claims.
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You must use the subscriber ID (including the two-digit suffix), NOT the Social Security number, to identify the patient on both electronic and paper claims. Claims submitted without a valid subscriber or Medicaid recipient ID number will be rejected.
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Billed charges must match the amount shown as billed on the EOB or your claim will be rejected as "Inappropriate EOB - does not match claim." You will then have to rebill the claim.
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Coding requirements: You must report valid CPT, ICD-9, and HCPCS codes when coding for services rendered. Claims containing invalid codes will be denied up front, and we will notify you within 48 hours of the denial. See the Diagnosis coding guidelines in this section.
Medicaid payments
If you are not currently contracted with the Priority Health Medicaid product, Priority Health will reimburse you at the Michigan Medicaid fee schedule. You may not balance-bill the member.
Go to the Michigan Medicaid fee schedule on the State of Michigan website. This link will open in a new browser window.
Deadlines for claim submission, resubmission & corrections
- Services must be billed within one year of the date of service.
- You may re-submit a claim if you do not receive a response within 45 days of submission.
- When another payer makes or recovers payment near or after our filing limit, you have 90 days from the date on the EOB to submit the claim to us. Submit both the claim AND the EOB for processing.
- Medicaid claims subject to third-party liability (TPL) investigation may be re-submitted after 180 days if no response is received from the member. See guidelines for resubmission.
- You must notify us immediately of any payment discrepancies (over or under). For contracted payments, we will make corrections up to one year from the date you notify us of the error.
- Follow-up, including resolving all claim discrepancies other than corrections to contracted payments mentioned above, must be completed within one year of the date of service. After that anniversary date claims will be denied as provider liability. There are no exceptions for negligence by provider billing services or provider staff.
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