Corrections to claims

Submit the entire claim with corrections

Submit your entire corrected claim, not just the line items that were corrected, following the processes below, either electronically or by U.S. Mail. Faxed or emailed claims are not accepted.

Corrected claims will pend, not deny as duplicate or redundant, without your needing to call or email us.

Checking claim status

Check the status of claims by using the Claims tool, or by calling the Provider Helpline.

Corrected vs. new claims

No payment - submit a new claim

If the entire claim allows zero dollars, make the appropriate changes and resubmit as a new claim. Do not submit as a corrected claim.

Claim example:

Claim line CPT code Charge amount Allowed amount Denial
1 99213 $55 $0 Not covered
2 81010 $35 $0 Not covered

Partial or full payment - submit a corrected claim

If a claim is partially paid (one or more claim lines were denied) or fully paid/allowed, make the appropriate changes for further payment consideration. Claim must be submitted as a corrected claim.

Claim example:

Claim line CPT code Charge amount Allowed amount Denial
1 99213 $55 $35 Paid
2 81010 $35 $0 Not covered

Adding a modifier

Submit medical records when appending a distinct service modifier (25, 59, or X[E, S, P, U]) to a line previously denied. 

See code modifier billing guidelines for more details.

Billing codes for corrections:

  • 7 - Replace (replacement/correction of prior claim)
  • 8 - Void (void/cancel of prior claim)

Submitting medical records

When you request an authorization, or a post payment appeal determination, you may need to send us medical records.

To submit medical records for a specific claim:

  1. Log into your prism account
  2. Click on Claims (medical)
  3. Search for your claim. Make sure you're logged in as the group or facility the claim was paid under.
  4. On the Claims Detail page, click Contact us.
  5. In the dropdown menu, select Medical records.
  6. Attach medical records to your message.

You’ll receive a confirmation screen after submitting your message, and a confirmation email from our Provider Services team.

To submit medical records for a Medicare claim for which you received a letter from us:

  1. Log into your prism account
  2. Click on General Requests
  3. Click on New Request
  4. In the dropdown menu, select Pended Claim requested medical records.
  5. Upload a copy of the letter we sent you requesting records.

If you don't have a prism account, create one now.

Claim correction deadlines and timely filing

Follow-up is required within one year of the date of service, including resolving all claim discrepancies. Corrected or augmented information received after that date will be automatically denied as the provider's responsibility.

Providers have 90 days from date of the original denial (if close to or beyond one year from date of service) to resolve payment discrepancies including submitting corrected claims. This does not include upfront rejected claims or other insurance adjustment EOBs.

  • If you don't complete follow-up within 90 days, any request will deny without appeal rights.
  • Corrected or augmented information received after that date will be automatically denied as the provider's responsibility.
  • Denials related to authorizations/medical necessity or coding/clinical edits still follow the filing limit rules.
  • Accidentally overlooking a claim or a response deadline does not justify an exception to this policy.

Medicaid, Medicare and Commercial claims processing

  • Claims must be processed within 45 days of when we receive them to comply with the Timelines of Claims Payment Public Act 187. 
  • We will notify you in writing of any problems or defects with your claim within 30 days; you will then have 30 days to correct and resubmit the claim.

90-day grace period

When Priority Health or another payer makes or recovers payment near or after our filing limit, you have 90 days from the date on the EOB to submit the claim to us. Payment corrections from another health plan require the claim and EOB to be submitted to Priority Health.

  • Attach the EOB to the claim so we can verify the claim was submitted to us within the 90 days. 
  • If you don't complete follow-up within 90 days, any request will deny without appeal rights. 
  • Corrected or augmented information received after that date will be automatically denied as the provider's responsibility. 
  • Denials related to authorizations/medical necessity or coding/clinical edits still follow the filing limit rules. 
  • Accidentally overlooking a claim or a response deadline does not justify an exception to this policy.