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

Fully denied claims - 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:

Approved paid claim submitted with $0 charge lines – submit a corrected claim If a claim is submitted with $0 charge lines, claim will be accepted and paid with $0 payment. Make the appropriate changes for further payment consideration. Claim must be submitted as a corrected claim.

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

Approved paid claim submitted with $0 charge lines – submit a corrected claim

If a claim is submitted with $0 charge lines, claim will be accepted and paid with $0 payment. Make the appropriate changes for further payment consideration. Claim must be submitted as corrected claim. 

Claim example:

Claim line	CPT code	Charge amount	Allowed amount	Denial
1	99213	$0	$0	Paid
2	81010	$0	$0	Paid

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)

Clinical edit for adjusted claims

For accurate identification of facility claim corrections, facilities should report the appropriate adjustment indicator for a corrected or voided/canceled claim along with the claim change reason code. To accurately identify these, report with one of the following bill types:

• Bill type xx7 should be reported to request an adjustment based on the corrected claim submission along with the appropriate claim change reason code (equal to condition codes D0-D4, D7, D8, D9*, or E0)
• Bill type xx8 should be reported to request the claim be voided or cancelled along with the appropriate claim change reason code (equal to condition codes D5 and D6)

Claims reported without this bill type and correct claim change reason code (see below) will be denied.

Claim change reason codes

• D0 - Changes to service dates
• D1 - Changes in charges
• D2 - Changes in revenue code/HCPC
• D3 - Second or subsequent interim PPS bill
• D4 - Change in Grouper input (DRG)
• D5 - Cancel only to correct a patient's Medicare ID number or provider number
• D6 - Cancel only - duplicate payment, outpatient to inpatient overlap, OIG overpayment
• D7 - Change to make Medicare secondary payer
• D8 - Change to make Medicare primary payer
• D9 - Any other changes (should be used only when no other change reason is applicable)

Use of condition code D9 should also include a remark to mirror bold criteria below on the second line of remarks:

• Patient control nbr - changing or adding a patient control number
• Admission hour - changing or adding the admission hour
• Admission type - changing or adding the admission type
• Admission source - changing or adding the admission source
• Medical record number - changing or adding the medical record number
• Condition code - changing or adding a condition code
• Occ codes - changing or adding an occurrence code
• Occ span codes - changing or adding an occurrence span code
• Value codes - changing or adding a value code
• Modifier - changing or adding a modifier
• Date of service - changing a date of service on a line or changing the statement from and to dates, use a D0
• Units - changing units
• Recalculation - claim recalculated for a different payment
• Multiple changes - enter your changes
• DX code - changing a diagnosis code on an outpatient claim, inpatient claims would use a D4
• POA - changing, adding, or removing a Present on Admission (POA) indicator, unless you are changing an N to a Y and/or if it affects reimbursement then you would use D4
• Removed non - removing non-covered charges
• Other - Place this information on the second line of the claim only. On the third line of claim include a brief description of why the claim is being adjusted

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 About this Claim
5. In the dropdown menu, select Submit 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 and payment 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.