Changes to provider dispute resolution submissions for coding and clinical edit issues

Effective Jan. 1, 2011, we’ll be implementing a new process related to submission of the Provider Appeal Form (formerly provider dispute resolution) for coding and clinical edit related issues.

Documents submitted without explanation (or Appeals form) as to why it is being submitted will be returned to you for additional information. With various different reasons for submission of claim attachments, it is imperative that an explanation relating to why information is being submitted accompanies the information received at Priority Health.

Submission of this information with little to no claim data attached delays our ability to process claim adjustments or resolve issues since there is no indication of what the issue is. By implementing this process, it will save administrative time for your practice and it will create a more efficient process that will allow us to resolve your issue in a timely manner. We’ll track requests and resolutions so that the work can be referenced in the future if providers have questions.

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