Reviews of claims and medical decisions under commercial plans

Complex claim reviews

For fastest response, use this process.

  1. Find the claim online using the Claims Inquiry tool.
  2. From the Remittance Advice (claim detail) screen, click Email Provider Services. You'll get an automated response giving you a claim inquiry reference number.
  3. A provider reimbursement analyst will respond to your inquiry within 5-7 business days.
  4. If your inquiry requires investigation by another department, we will notify you within the 5-7 business days.
  5. If you are not satisfied with the outcome of the informal review, you may file a Level I appeal.

Coding or clinical edit question reviews

  1. Go to your Priority Health account mailbox and compose a message. Choose Clinical edit as the "To" choice.
  2. Explain your question about coding, clinical edit rationale or clinical edit upfront rejection (e.g., invalid procedure code and modifier combination). You'll get an automated email giving you a claim inquiry reference number.
  3. A coding analyst will reply with an explanation within 5-7 business days.
  4. If you haven't received a response within 45 days, reply to the email that contains your inquiry number.
  5. If you are not satisfied with the informal review explanation, you may file a Level I appeal.

Medical reviews

  1. Follow the directions for submitting medical records, below.
  2. We make a decision within 30 days of the date we receive all documentation.
  3. We inform you of the outcome of reviews by remittance advice within 5 business days of the decision.
  4. If you are not satisfied with the informal review explanation, you may file a Level I appeal.

Submitting medical records

When you request an authorization, or a post payment appeal determination, you may need to send us medical records. Use your secure mailbox to send the forms to us via email or mail us a hard copy. To access your secure mailbox: 

  1. Go to your Priority Health account Mailbox.
  2. Click the Compose tab.
  3. In the "What is your message about?" field, choose Medical record submission.
  4. Use the Attachments field to browse to your documents and attach them.
  5. In the body of the email include: member name, DOB, member ID number, claim/DCN number, date of service, billed amount, and inquiry number, if you have one.
  6. If you are submitting an appeal; you must complete and attach the most current Priority Health appeal form and submit a detailed letter of appeal. For more information  on appeals access our Reviews and appeals requirements.

If you don't have a Priority Health provider account, request one now.