CODA audits
The scope of our Claims Opportunity Detection Audits (CODA) program with vendor Performant Recovery Inc. includes duplicate claims for professional, outpatient and inpatient services. These audits appear as denials on your remittance advice with codes GBC, GBF or OZ5.
Level I disputes
If you receive a claim denial for duplicate services and/or a CODA adjustment and wish to dispute the decision, follow our claim reviews and appeals process.
Technical denials
For each claim requiring medical record review, three request letters are sent. When a provider doesn’t respond to these requests – whether from Priority Health or one of our vendors – by the deadline, we’re unable to substantiate the care provided and will issue a technical denial.
This is a denial of the entire paid claim, after which we'll recoup funds following our standard process for correcting overpayments.
To dispute a technical denial, follow the appeal process for the appropriate audit type.