Special Investigations Unit audit disputes
The Priority Health Special Investigations Unit (SIU) performs audits based on leads from our Fraud, Waste & Abuse program. The audits may be desk level, on-site or a combination of both.
Our goal is to reach a resolution understood and agreed to by both parties. This requires a collaborative process, so we encourage ongoing communication, conference calls and/or in-person meetings to assist in understanding all parties' concerns and regulatory requirements.
This dispute process does not supersede contract terms or agreements.
Level I SIU audit disputes
Providers receive a written notice detailing the audit results. To dispute the findings, submit a formal written appeal letter along with relevant documents within the timeframe indicated in the overpayment letter. We may grant requests for reasonable extensions if you contact us prior to the due date.
- Overpayment reimbursement requests and/or other actions named in the written notice are placed on hold until the dispute is resolved.
- The dispute will be reviewed by licensed or credentialed personnel.
- A physician will review all medical necessity cases.
Providers receive a Level I audit dispute outcome letter detailing the results of our review.
Level II SIU audit disputes
Providers may dispute the Level I dispute outcome by submitting a written summary of their concerns, together with supporting documentation not previously submitted.
You must open a Level II dispute within 45 days of receiving our Level I findings.
Once we receive your Level II dispute, it is reviewed by the auditor as well as a different individual than whomever made the initial determination.
SIU contact information
Send dispute letters to Priority Health at:
Mail: Priority Health
Attn: SIU MS 3175
1231 E. Beltline NE
Grand Rapids, MI 49525