Corrections to claims
Submit the entire claim with corrections
Submit your entire corrected claim, not just the line items that were corrected, following the processes below, either electronically or by U.S. Mail. Faxed or emailed claims are not accepted.
Corrected claims will pend, not deny as duplicate or redundant, without your needing to call or email us.
Checking claim status
Check the status of claims by using the Claims tool, or by calling the Provider Helpline.
Corrected vs. new claims
No payment - submit a new claim
If the entire claim allows zero dollars, make the appropriate changes and resubmit as a new claim. Do not submit as a corrected claim.
Claim example:
Claim line | CPT code | Charge amount | Allowed amount | Denial |
---|---|---|---|---|
1 | 99213 | $55 | $0 | Not covered |
2 | 81010 | $35 | $0 | Not covered |
Partial or full payment - submit a corrected claim
If a claim is partially paid (one or more claim lines were denied) or fully paid/allowed, make the appropriate changes for further payment consideration. Claim must be submitted as a corrected claim.
Claim example:
Claim line | CPT code | Charge amount | Allowed amount | Denial |
---|---|---|---|---|
1 | 99213 | $55 | $35 | Paid |
2 | 81010 | $35 | $0 | Not covered |
Adding a modifier
Submit medical records when appending a distinct service modifier (25, 59, or X[E, S, P, U]) to a line previously denied.
See code modifier billing guidelines for more details.
Billing codes for corrections:
- 7 - Replace (replacement/correction of prior claim)
- 8 - Void (void/cancel of prior claim)
Submitting medical records
When you request an authorization, or a post payment appeal determination, you may need to send us medical records.
To submit medical records for a specific claim:
- Log into your prism account
- Click on Claims (medical)
- Search for your claim. Make sure you're logged in as the group or facility the claim was paid under.
- On the Claims Detail page, click Contact us.
- In the dropdown menu, select Medical records.
- Attach medical records to your message.
You’ll receive a confirmation screen after submitting your message, and a confirmation email from our Provider Services team.
To submit medical records for a Medicare claim for which you received a letter from us:
- Log into your prism account
- Click on General Requests
- Click on New Request
- In the dropdown menu, select Pended Claim requested medical records.
- Upload a copy of the letter we sent you requesting records.
If you don't have a prism account, create one now.
Claim correction deadlines and timely filing
Follow-up is required within one year of the date of service, including resolving all claim discrepancies. Corrected or augmented information received after that date will be automatically denied as the provider's responsibility.
Providers have 90 days from date of the original denial (if close to or beyond one year from date of service) to resolve payment discrepancies including submitting corrected claims. This does not include upfront rejected claims or other insurance adjustment EOBs.
- If you don't complete follow-up within 90 days, any request will deny without appeal rights.
- Corrected or augmented information received after that date will be automatically denied as the provider's responsibility.
- Denials related to authorizations/medical necessity or coding/clinical edits still follow the filing limit rules.
- Accidentally overlooking a claim or a response deadline does not justify an exception to this policy.
Medicaid, Medicare and Commercial claims processing
- Claims must be processed within 45 days of when we receive them to comply with the Timelines of Claims Payment Public Act 187.
- We will notify you in writing of any problems or defects with your claim within 30 days; you will then have 30 days to correct and resubmit the claim.
90-day grace period
When Priority Health or another payer makes or recovers payment near or after our filing limit, you have 90 days from the date on the EOB to submit the claim to us. Payment corrections from another health plan require the claim and EOB to be submitted to Priority Health.
- Attach the EOB to the claim so we can verify the claim was submitted to us within the 90 days.
- If you don't complete follow-up within 90 days, any request will deny without appeal rights.
- Corrected or augmented information received after that date will be automatically denied as the provider's responsibility.
- Denials related to authorizations/medical necessity or coding/clinical edits still follow the filing limit rules.
- Accidentally overlooking a claim or a response deadline does not justify an exception to this policy.
- Status claims
- Claims Inquiry tool guide
- Edits Checker tool guide
- Claim deadlines
- Set up electronic payments
- BH provider billing
- Facility billing
- Advanced practice professional billing
- Professional billing
More billing topics:
- ACA non-payment grace period
- Ambulatory surgery center billing
- Balance billing
- Clinical edits
- Check reissue procedure
- COB: Coordination of benefits
- Correcting claims
- Correcting overpayments & underpayments
- Diagnosis coding
- Dual-eligible members
- Front-end rejections
- Gender-specific services
- Medicaid billing
- Modifiers
- NDC numbers on drug claims
- Office-based procedures billing
- Risk adjustment
- Unlisted codes, drugs & supplies
Correcting or appealing a claim?
Include all records for the date of service to avoid processing delays.
Submitting electronic claims
How to set up HIPAA-compliant electronic (EDI) claim files.
Mailing paper claims
Priority Health Claims
P.O. Box 232
Grand Rapids, MI 49501