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 appeal.
A Level 2 dispute must include additional documentation to support services rendered or payment expected. We won't accept appeals from providers that did not perform the service.
When to submit a Level 2 dispute:
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:
- Make sure the documentation supports the claim dispute
- Send final documents only, not preliminary results
- Only send paperwork related to the specific date of service in question
- Send only what’s relevant – we don’t need discharge paperwork, service orders etc. Don’t include corrected claims or new claims to be processed.
In addition to supporting documentation, you’ll also need to upload:
- Provider letter with a detailed summary of what is being disputed and why
- Supporting clinical documentation including: admission summary, physician, documentation, medical testing and a discharge summary, if applicable
- Priority Health denial letter (recommended)
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.
Supporting documentation can include contract language, CMS information, proof of timely filing, etc. 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.
Also include the following, as appropriate:
Specifics on what was denied and the cited reason for denial
Fee schedules
Any justification that supports your appeal - 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 appeal
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