Claim Disputes

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Steps for Claim Payment Disputes

The provider payment dispute process consists of two internal steps. The steps are:

  1. Claim payment reconsiderations
  2. Claim payment appeals (with the consent of the member)

Claim payment reconsiderations represent your initial request for an investigation into the outcome of the claim. Most issues are resolved during this step. Claim payment appeals can be submitted if you disagree with the outcome of the claim payment reconsideration. You must have the member's consent to submit an appeal.

Providers will not be penalized for filing a claim payment dispute, nor is there any action required by the member. While a full list of claim payment dispute reasons can be located in the provider manual, some of the most common reasons for submitting a dispute include:

  • Contractual payment issues.
  • Disagreements over reduced or zero-paid claims.
  • Post-service authorization issues.
  • Other health insurance denial issues.
  • Timely filing issues.

For timely filing issues, we consider reimbursement of a claim that has been denied due to failure to meet timely filing if you can provide documentation showing the claim was submitted within the timely filing limit or demonstrate good cause exists.

What to do Before Submitting a Claim Dispute

Before submitting a claim dispute, be sure you have thoroughly reviewed the processing or denial of the claim. You can access My Insurance Manager to get additional details on the claim. If the issue remains unresolved, you can proceed with submitting the dispute. Be sure to gather all supporting documentation (i.e., medical records, doctor's notes, etc.) so it can be included with your submission.

How To Submit Claim Disputes

Claim payment disputes can be submitted in two ways.

      Healthy Blue
      P.O. Box 100317
      Columbia, SC 29202-3317