This is your second opportunity to dispute a claim decision.
If you’re not satisfied with the outcome of your Level 1 claim dispute decision, you can submit a Level 2 claim dispute, with additional background and criteria required. By submitting a Level 2 claim dispute, you’re formally requesting that we re-examine our initial adverse determination on an existing claim.
Important to note:
- A Level 1 claim dispute decision is needed in our Provider Portal before you can submit a Level 2. You cannot skip to Level 2.
- You may submit a Level 2 claim dispute (formerly called Appeal) only once per claim.
- We only accept Level 2 disputes from providers that performed the service.
- Any Level 2 claim dispute that has already been reviewed and is subsequently reopened will be closed without review.
Deadline for submitting Level 2 claim disputes
You must submit your Level 2 dispute within 180 days of the remittance advice.
What will you need?
- Claim ID for the most current claim. We’ll close claim disputes without review when a claim is resubmitted after the dispute was filed.
- Denial reason applied to the claim or claim line.
- Specific Priority Health billing and/or medical policy that is applicable to the denial and proves the claim deviated from them.
- Regulatory, non-Priority Health billing and coding guidelines, or contract language.
- Supporting documentation applicable to the service under dispute. We’ll close claim disputes submitted with the full medical record.
- Detailed summary of why you believe the claim deviated from our Priority Health billing and/or medical policies, and/or contract. This should be very specific. We’ll close claim disputes with statements such as “this is coded correctly” or “please review records” as these don’t support a claim dispute rationale.
Please note that cover letters will no longer be accepted as part of the dispute process. All required information must be clearly documented within the dispute submission itself.
How to submit a Level 2 claim dispute
Make sure you've completed the Level 1 claim dispute process first.
Process for in-network providers
- Log into your Provider Portal account.
- Navigate to the claim in question through either Claims in the main menu, or, if you're viewing the member's Member Snapshot / Member Inquiry screen, hover your cursor over the member's name in the main menu and click Claim by Member. Search for the claim and then click the Claim # to open the Claim Details screen.
- On the Claims Detail screen, review the claim details, including the description of any clinical edits that may have applied. If you still have a question, hover your cursor over Ask A Question in the top right corner of the screen, then click Level 2 Claim Dispute. This will open a new window.
Complete all fields – including the disputed code and a detailed rationale referencing the specific Priority Health billing and/or medical policy – and attach supporting documentation from regulatory, non-Priority Health billing and coding guidelines, or contract language. Click Submit.
Process for out-of-network providers
- Fastest (preferred): The servicing provider submits the Level 2 claim dispute through our Provider Portal, using the process outlined above. Any provider can create a Provider Portal account. If you don't have one already, create one now.
- Alternative: The servicing provider completes and submits the Out-of-network/Out-of-state provider claim dispute form.
After submitting your Level 2 claim dispute
We’ll review the contractual, benefit claims and medical record information.
We'll inform you of the outcome of our review either by remittance advice, adverse determination letter or via a comment on the message (In Basked or CRM) in our Provider Portal within:
- 60 calendar days of the submission for coding/clinical edit disputes
- 60 calendar days of the submission for medical necessity appeals
- 45 calendar days of the submission for all other claim disputes