The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage Organizations (MAOs), including Priority Health Medicare, to have a provider claim dispute process that includes:
- Asking for a review of claims payment
- Making a claim dispute on behalf of a member
Plans included:
This CMS process applies to Medicare-covered medical services and supplies for patients covered by:
- Priority Health Medicare Advantage plans
- Employer group Medicare plans covering their retirees
Step 1: Level 1 claim dispute
You must wait 45 days after submitting a Level 1 claim dispute (formerly called Review).
You must complete the Level 1 claim dispute process and receive a decision before submitting a Level 2 claim dispute. (The Level 1 claim dispute process for Medicare is the same as for commercial plans).
Step 2: Level 2 claim dispute
Definition of a Level 2 claim dispute
A Level 2 claim dispute (formerly called Appeal) is a formal request by a provider for Priority Health to re-examine its initial adverse determination of a claim after a Level 1 claim dispute process is completed. If you haven't completed Level 1 claim dispute, we won't process your Level 2 dispute.
A Level 2 dispute must include additional documentation to support services rendered or payment expected. We won't accept disputes from providers that did not perform the service.
Non-disputable denials
Inaccurate coding or billing denials for services are not disputable denials. These denials require correction through corrected claim process.- Missing modifiers
- Missing laterality in diagnosis or modifier
- Incorrect place of service
- APC Edit Claim Denials
- Incorrect procedure codes for governmental claims (i.e. G-Codes)
Deadline for Level 2 claim disputes
You must submit your Level 2 claim dispute within 180 days of the remittance advice.
What will you need?
When you submit your Level 2 claim dispute, you must upload additional documentation to support the services rendered or payment expected. Here’s our tips for choosing what documents to upload:
- 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.
- Attach any Policy or clinical guidelines applicable to the denial.
- Attach any regulatory, billing, coding guidelines or contract language.
- Supporting documentation applicable to the service under dispute. We’ll close claim disputes submitted with the full medical record.
- Summary of why you believe the claim didn’t process in accordance with the guidelines, policy 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.
How to submit a Level 2 claim dispute
Make sure you're completed the Level 1 claim dispute process first.
Process for in-network providers
- Log into your prism account.
- Click Appeals and then New Post-Claim Appeal then search for and click on the claim number you wish to dispute.
- On the Claims Detail screen, click Contact us about this claim.
- In the drop-down menu, select Appeals.
- Enter your name, phone number, message – including the disputed code – and attachments. Make sure to include supporting documentation (see below) for your request as described above.
- Note: We won't accept the following as supporting documentation: remittance advice, a copy of a claim, a system print out – we'll close the inquiry. Additionally, we don't accept medical records for claim appeals unless specifically requested.
- Click Submit. Your inquiry will appear within the Appeals list page upon submission
Process for out-of-network providers
See the following pages for instructions:
- Medicare non-contracted provider payment disputes
- Medicare appeals post service: Non-contracted provider
After submitting your Level 2 dispute
Our specialists will 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 inquiry in prism within:
- 30 calendar days of submission for claim disputes
- 60 calendar days of submission for medical necessity appeals