Informal reviews under Medicaid

Waiting period

You must wait 45 days after submitting a claim to request a review.

Complex claim reviews

For fastest response, use this process.

  1. Find the claim online using the Claims tool.
  2. From the remittance advice (claim detail) screen, click Contact us. You'll get an automated response with 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'll notify you within 5-7 business days.
  5. If you're not satisfied with the outcome of the informal review, you can file a Level I appeal.

Coding or clinical edit question reviews

  1. Go to your Priority Health Secure 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 with 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're not satisfied with the informal review explanation, you can file a Level I appeal.