This is your first opportunity to dispute a claim decision.
If a claim wasn't processed correctly based on our policies, your first step is to submit a Level 1 claim dispute. We require documentation that outlines where we deviated from our Billing & Coding policies and regulatory standards.
Important to note:
- A Level 1 claim dispute decision is needed in our Provider Portal before you can submit a Level 2. You cannot skip to Level 2.
You may submit a Level 1 claim dispute only once per claim.
We won’t accept a Level 2 claim dispute until this process is complete.
- We only accept Level 1 disputes from providers that performed the service.
Important: Level 1 claim disputes that have been reviewed and closed, and then reopened by the provider will be closed without review. In order to receive an additional review by our team, you must submit a Level 2 claim dispute in our Provider Portal.
Waiting period
You must wait 45 days after submitting a claim to submit a Level 1 claim dispute (formerly called Review) and a decision is required before you can file a Level 2 claim dispute (formerly called Appeal).
Level 1 claim disputes
As a first step, you must review your claim denial details in our Provider Portal, along with our Provider Manual and Billing & Coding Policies, to determine the reason for the denial.
Inaccurate coding or billing denials for services are not disputable denials. These denials require correction through the 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)
This is not an all-inclusive list.
What will you need?
- 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.
- Specific Priority Health billing policy and/or medical policy that is applicable to the denial and proves the claim deviated from them.
- Regulatory or non-Priority Health billing and coding guidelines or contract language.
- Supporting documentation applicable to the service under dispute. We’ll close claim disputes submitted with the full medical record.
- Detailed summary of why you believe the claim deviated from our Priority Health billing and/or medical policies, 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.
Please note that cover letters will no longer be accepted as part of the dispute process. All required information must be clearly documented within the dispute submission itself.
How to submit your request
- Log into your Provider Portal account.
- Navigate to the claim in question through either Claims in the main menu, or, if you're viewing the member's Member Snapshot / Member Inquiry screen, hover your cursor over the member's name in the main menu and click Claim by Member. Search for the claim and then click the Claim # to open the Claim Details screen.
- On the Claims Detail screen, review the claim details, including the description of any clinical edits that may have applied. If you still have a question, hover your cursor over Ask A Question in the top right corner of the screen, then click Level 1 Claim Dispute. This will open a new window.
- Complete all fields, include the disputed code and a detailed rationale referencing the specific Priority Health billing and/or medical policies and attach supporting documentation from regulatory, non-Priority Health billing and coding guidelines, or contract language. Write us a clear and concise summary within the message field and click Submit.
What happens after you submit?
You can track a claim dispute's status in your In Basket or CRMs. The subject line will contain "Claim Dispute." We’ll respond to your inquiry within the following timelines:
- 15 calendar days - Questions about your claim (Level 1 Claim Dispute)
- 60 calendar days - Appeals (Level 2 Claim Dispute)
To see our response in your portal account, go to In Basket or CRM in the main menu, open the message and look at the dispute status at the bottom of the screen. You'll receive an automated email notification when a comment has been entered on your inquiry, if your portal notification preferences are set up to receive these alerts. If your inquiry requires investigation by another department, we'll notify you via a comment on your inquiry within the above timeframes.
Claim review process
Claims are reviewed and responded to in the order they were received within the above timeframes. Claim reviews can’t be escalated by emailing us for an update on your claim.
If you encounter an issue with over 100 claims, and you have already submitted at least one Level 1 Claim Dispute, you can email us at exceedsprocessingtime@priorityhealth.com with that CRM ID number. All other emails sent will receive a response that we are processing inquiries per our first-in-first-out policy.
Important: Level 1 claim disputes that have been reviewed and closed, and then reopened by the provider, will be closed without review. In order to receive an additional review by our team, you must submit a Level 2 claim dispute in our Provider Portal.
Itemized Bill Reviews (IBR)
Follow this Level 1 claim dispute process to submit questions related to Itemized Bill Reviews (IBR). After you submit your dispute, we’ll follow up with a detailed breakdown of the review outcome, routing any further questions to our Payment Integrity team.
Third-party liability (TPL)
Follow this Level 1 claim dispute process when the claim denied for TPL investigation/TPL primary and you're submitting documentation for our Third-Party Liability department to review.
Coordination of benefits (COB)
Follow this Level 1 claim dispute process when the claim has been denied for COB investigation/other insurance primary information and you're submitting documentation (i.e., primary insurance EOB or documentation of no other insurance coverage for a member etc.) for our COB department to review.