Match member information on claims to member ID and legal identification

We recently tightened our criteria for matching a claim to a member. Since this update, we’ve seen an increase in front-end rejections due to elements on the claim not matching the member information in our system.

Our current criteria

Below are the criteria our system looks at to match a claim to one of our members. If any of these don’t match exactly what we have in our system, the claim will be rejected.

  1. Billed Member ID (recognized lengths below)
    Medicaid ID: 8-10 digits
    Commercial & Medicare ID: 9-12 digits, with or without any dash and suffix
  2. First Name: First 3 characters must match, max of 60 characters allowed
  3. Last Name: First 3 characters must match, max of 35 characters allowed
  4. Date of Birth: YYYYMMDD
  5. Gender: M or F

Claim rejection message

When any of the above criteria doesn’t match one of our members, the claim will reject, and you’ll receive this message on your service receipt:

Please verify accuracy of contract # on PH Member ID. Last name, first name, DOB and gender must match legal identification.

Common criteria mismatches

The following are common issues we’re seeing that are resulting in claim rejections:

  • Middle initial is appended to the first name through your clearinghouse
  • Nicknames or shortened names used instead of legal names
  • Gender entered as Unknown (M or F must be selected. For information on gender specific services and condition code 45, see our Provider Manual.)

What to do when you receive this rejection

In prism, under Member Inquiry, lookup the member in question to see what we have in our system. If the information in Member Inquiry doesn’t match the member’s legal ID, let the member know they must update their enrollment file with their employer, Medicare or Medicaid.

We receive our enrollment files directly from these sources. If the member calls Priority Health, we’ll refer them to the appropriate source to update their information.

For Medicare and Medicaid members, submit your claim with the member’s information as it appears in the Medicare and Medicaid software systems.

What to do if you receive this rejection, but everything matches

Contact our Provider Helpline for support at 800.942.4765, available Monday-Thursday from 7:30 a.m. – 5 p.m. and Friday from 9 a.m. – 5 p.m.