Earlier this year, we changed our claim dispute process. Here is some important information about the new process.
How to submit claim disputes
Your first opportunity to dispute a claim decision is a Level 1 claim dispute. If you call the Provider Call Center, and the representative escalates the claim on your behalf for review, this counts as the Level 1 claim dispute, in most cases. Instead of this, the preferred method is to submit your Level 1 claim dispute in prism. (Note: call center representatives cannot receive documentation to attach to your request.) Using our online tool will allow you to upload supporting documentation, allowing for a more effective and efficient dispute.
To submit a Level 1 claim dispute via prism, use the “Contact us about this claim” option in prism (use our guide for step-by-step instructions).
Include documentation with your dispute
For the most effective dispute, complete all fields, and attach documentation to support how the claim deviates from our established billing and coding policies, regulatory, contract language or fee schedules. Write a clear and concise summary in the message field. Submissions lacking required documentation will be considered invalid and won’t be processed.
Move to a Level 2 claim dispute if needed
Don’t attempt to reopen Level 1 claim disputes that have already been reviewed and closed. These will be closed without review. Rather, if you don’t agree with the outcome and would like our team to do an additional review, submit a Level 2 claim dispute in prism (use our guide for step-by-step instructions). Providers are allowed one Level 1 claim dispute and one Level 2 claim dispute per claim.
Still have questions?
For more information and for detailed steps to follow, please refer to our Provider Manual or our Get your questions answered guide.