Informal reviews under Medicaid
You must wait 45 days after submitting a claim to request a review.
Complex claim reviews
For fastest response, use this process.
- Find the claim online using the Claims tool.
- From the remittance advice (claim detail) screen, click Contact us. You'll get an automated response with a claim inquiry reference number.
- A provider reimbursement analyst will respond to your inquiry within 5-7 business days.
- If your inquiry requires investigation by another department, we'll notify you within 5-7 business days.
- 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
- Go to your Priority Health Secure Mailbox and compose a message. Choose Clinical edit as the "To" choice.
- 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.
- A coding analyst will reply with an explanation within 5-7 business days.
- If you haven't received a response within 45 days, reply to the email that contains your inquiry number.
- If you're not satisfied with the informal review explanation, you can file a Level I appeal.