Correcting Claims & Payments

Submit your entire corrected claim to Priority Health, not just the line items that were corrected, following the processes below. Corrected claims will pend, not deny as duplicate or redundant, without your needing to call or fax us.

Check the status of claims you have submitted by logging in to the Provider Center and using the Claims tool, or by calling the Provider Help Line.

Go to Correcting Electronic 1500 Claims, below
Go to Correcting a Paper HCFA 1500, below
Go to Correcting Facility Claims page
Go to Correcting Over- or Under-Payments page

Types of Billing Codes:
   1 - Original (admission through discharge)
   7 - Replace (replacement/correction of prior claim)
   8 - Void (void/cancel of prior claim)

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Correcting Electronic 1500 Claims
If you don't know where the 2300 loop or 2300 NTE ADD fields are in the form you use, contact your software vendor. If your software vendor has additional questions, direct them to call the EDI Helpline.

1. Enter Claim Frequency Type Code (billing code) 7 (for a replacement/correction) or 8 (to void a prior claim) in the 2300 loop in the CLM*05 03. 
2. To ensure we process the claim accurately, add a note that indicates the reason for the resubmission. Place the note in loop 2300 NTE (segment) ADD (Qualifier). For example: NTE*ADD* (changed CPT)

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Correcting a Paper HCFA 1500

1. In box 22 (Medicaid Resubmission), enter 7 (the "Replace" billing code). This will notify us that this is a corrected or replacement claim, and the claims examiners will not deny it as a duplicate claim. Use box 22 for this regardless of which Priority Health plan covers the patient.
   
2. In box 19, add a note to indicate the reason for the resubmission. Examples: Changed CPT, added modifier, corrected EOB, etc. PLEASE WRITE LEGIBLY.
   
3. If you are adding or changing clinical information on the claim, attach documentation.
4. Mail the corrected claim to the appropriate Priority Health claims processing address. You don't need to call or fax us to alert us to your correction.

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Correction Timelines

Follow-up is required within one year of the date of service, including resolving all claim discrepancies. Corrected or augmented information received after that date will be automatically denied as the provider's responsibility. Negligence by the provider's staff does not justify an exception to this policy.

Medicaid claims must be processed within 45 days of when we receive them to comply with the Timelines of Claims Payment Public Act 187. We will notify you in writing of any problems or defects with your claim within 30 days; you will then have 30 days to correct and resubmit the claim.