We’ve made some changes to our claim disputes process to streamline options for you and align with industry best practices. We’ve also made changes to the requirements for escalating claims.
Changes in the prism “Contact Us” menu
We’ve streamlined the Contact Us options by reducing the options to just two – making it easier and faster to get the support you need. The two options are Question About My Claim and Appeals. This will reduce confusion and help eliminate routing issues.
Terminology for post-claim Reviews/Appeals
We’ve updated our terminology to better align with industry standards. An Informal Review is now referred to as a Level 1 claim dispute, and a claim Appeal is now a Level 2 claim dispute. These changes are designed to improve clarity and consistency. Note: these changes do not impact our terminology for medical necessity authorizations.
Documentation requirements when submitting claim disputes
We’ve updated the documentation requirements for claim dispute submissions to align with industry standards, ensuring faster, more consistent processing. All disputes must include a clear, concise summary explaining how the claim differs from our Billing and Coding policies. Restating denial messages or remittance details without identifying a specific policy variance does not meet submission requirements. Cover letters will no longer be accepted; all required information must be entered directly into the message box of the inquiry. These changes are detailed in our Provider Manual.
Escalation emails
Effective immediately, you’ll no longer be able to use exceedsprocessingtime@priorityhealth.com when inquiries have exceeded established service level agreements. Instead, this email should only be used to escalate an inquiry when the issue being identified is impacting over 100 claims. This ensures that systemic problems are identified and addressed promptly. Note: please only submit one email notifying us of the issue, including the submitted inquiry number.
Reminders
- As of August, we started processing all inquiries using a first-in-first-out (FIFO) approach, meaning inquiries are addressed in the order they’re received, not the last date reviewed.
- Prior to submitting a claim dispute, you must review your claim denial details in prism, along with our Provider Manual and Billing and Coding Policies, to determine the reason for the denial.
For more details about these changes and other tips on submitting claim disputes, check out our most recent Billing & Coding webinar from Jan. 29.