New Provider Resolution Operations hub available May 1
Effective immediately, the provider reimbursement team has streamlined the post-payment email and appeal processes for providers. We've united the Provider Services, Code Review and Medical operations teams in a central intake hub called Provider Resolution Operations (PRO), reachable at firstname.lastname@example.org or 616.975.8856.
This allows for faster turn-around times for post-service inquiries. By aligning team members from each area, PRO can move email inquiries to the correct location the first time, reducing the volume of routing between departments. All post-payment inquiries will route PRO for processing.
What is changing?
Changes to the process effective May 1, 2017 are:
Authorization for services that have not yet been rendered should be requested online when possible, by using Auth Request (participating providers) or the fax forms (non-par providers). You can check the auth reference list in the Provider Manual to see if services require authorization.
All faxes require a cover sheet. We will be providing a fax-back notification confirming receipt of your request and a unique inquiry number for tracking your fax.
All medical records must be sent to us securely. Log in to your Priority Health account, click your Mailbox in the green menu bar and select "compose a message." For the "To" address, choose "medical record submission" from the drop-down list. Reference the inquiry number if you have one.
- Emailed requests will be completed within 45 business days when received with necessary supporting documentation.
- Once a decision is made, we will inform you of the outcome of the review by remittance advice within five business days of the decision.
Provider Level I and II appeal forms have been simplified and updated to include the one fax number of 616.975.8856. An informal review must be completed prior to filing an appeal with the exception of clinical edit/correct coding denials, which should be completed on the appeal form. See the Reviews and appeals for more details.