The information below applies to contracted and non-contracted providers.

If you notice an error on your remittance advice (RA), call the Provider Helpline at 800.942.4765 with details about the error.

Over/underpayments

Less than $200 to physicians/less than $5,000 to facilities

Priority Health will make the necessary corrections and adjustments on a future remittance advice (RA).

Greater than $200 to physicians/greater than $5,000 to facilities

In most instances, Priority Health sends your office a letter requesting repayment.  This letter is the only form of notification your office will receive.  The claim will not appear on your remittance advice and cannot be viewed on the web. There may be instances, however, where Priority Health will take the necessary corrections and adjustments on a future remittance advice (ie: Claim reprocessed via an internal configuration log).

Monthly statement of outstanding overpayments

Priority Health Finance sends a monthly statement of the outstanding overpayment to the provider until the overpayment is settled and no longer has a balance due. 

This statement will list:

• Patient account information
• Date of service
• Billed changes
• Date claim was originally paid
• Reason for take-back

To return an overpayment to Priority Health

You have four options for letting us know you are returning an overpayment:

• Complete a refund form, explaining the reason for the return

• Print a refund form

• Copy the overpayment letter from Priority Health
• Copy the remittance advice and highlight the member and reason for return
• Send a letter with:
  • member name
  • member ID number and claim number
  • date of service
  • reason for return

Mail any one of the above documents with your refund check to:

Priority Health

Attn: Overpayment Refunds

1705 Reliable Parkway

Chicago, IL 60686

Timelines for Priority Health resolving an underpayment

Priority Health handles reprocessing of underpayments up to 12 months prior to the date that Priority Health was notified of the issue. 

Timelines for Priority Health recovering an overpayment

Priority Health handles recovery of overpayments ("take-backs") according to the situation that created the overpayment and the time frame between when the payment was made and when the overpayment was identified.

• Member retro-terminations:

  The adjustment and/or the initial notification date for recovery will be limited to 12 months from date of payment. Member liability exists.

• Coordination of benefits:

  The adjustment and/or the initial notification date for recovery will be limited to 12 months from date of payment. Member liability may exist.

• Inaccurate payment:

  This includes duplicate payment, system set-up error, claim processing error, claims paid to wrong provider. The adjustment and/or the initial  notification date for recovery will be limited to 12 months from date of payment.

• Identified through a medical record audit:

  The adjustment and/or the initial notification date for recovery will be limited to 18 months from date of payment. Time period starts from audit notification date.

• Fraud and abuse:

  The adjustment and/or the initial notification date for recovery time period will be the statute of limitations.

For more information, providers should review their Priority Health contracts or call the Provider Helpline at 800.942.4765.

Tracking the take-back/credit balance forward (CBF)

You should refund any overpayment as soon as it is identified. 

• If, after 90 days, we have not received your refund, our Finance Department will automatically attempt to take the payment back on a future remittance advice (RA). If we receive no further claims from you, we may place the take-back in collections.
• We may attempt to recover the balance due from any entity sharing the same tax ID. 
• A change in tax ID does not eliminate liability for overpayments due back to Priority Health. We may attempt to recover the balance due from the new entity if we receive record of a tax ID update. 
• The take-back amount will appear as a negative payment on the remittance advice that is offset with dollars being paid on another claim for a member with the same plan (HMO, POS, PPO, etc.). If no further claims are paid from the same plan, Priority Health may attempt to collect the funds from payments on another Priority Health plan.
• Each self-funded (SF) group is its own line of business, so Priority Health may attempt to take back dollars being paid on another  claim for another member in the same group or from payment on another Priority Health plan.
• If the dollar amount of the overpayment is greater than the dollar amount owed to you on the RA, there will be no check issued you with the RA. In this case, the take-back amount may be taken out of more than one RA until the amount is recovered.
• You will see the claim that created the take-back amount on the last page of the RA.