New denial process for invalid codes

Priority Health guidelines require that providers report valid CPT, ICD-9, and HCPCS codes when coding for services rendered.

Effective October 1, 2007, Priority Health will begin an upfront denial process that will let providers know earlier when their claims are being denied for invalid codes. This new EDI process will adjudicate both paper and electronic claims up front.

1. Claims identified with an invalid code will be denied in their entirety.
2. Priority Health will send a notification to the provider within 48 hours of the rejection either by fax, e-mail, or letter.
3. After correcting the claim, providers may resubmit them for processing.

Examples of invalid codes that will deny:
99213-59 (invalid code/modifier combination)
20610-25 (invalid code/modifier combination)
625.4 reported for a male member (invalid diagnosis for gender)
625 (title diagnosis, requires fourth digit)

If you have questions, contact the Provider Help Line or your account representative.