Provider Disputes

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Provider Dispute Process

We accept provider dispute requests in writing, verbally, in-person and through our secure provider website within 90 calendar days of the date on the Explanation of Payment. Provider disputes filed more than 90 days from the Explanation of Payment are considered untimely and denied unless good cause can be established. We are unable to process a provider dispute without a finalized claim on file.

Providers will not be penalized for requesting a dispute, nor is there any action required by the member. While a full list of provider 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.

There are three common, claim-related issues that are not considered provider disputes. To avoid confusion with provider disputes, we’ve defined them briefly here:

  • Claim inquiry: a question about a claim but not a request to change a claim payment.
  • Claims correspondence: when Healthy Blue requests further information to finalize a claim; typically includes medical records, itemized bills or information about other insurance a member may have.
  • Medical necessity appeals: a preservice appeal for a denied service in which a claim has not yet been submitted.

What to do Before Submitting a Provider Dispute

Before submitting a provider 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.

Required Documentation for Provider Disputes

Healthy Blue requires the following information when submitting a provider dispute:

  • Your name, address, phone number, email, and either your NPI or TIN
  • The member’s name and Healthy Blue Medicaid ID number
  • A listing of disputed claims, including the Healthy Blue claim number and the date(s) of service(s)
  • All supporting statements and documentation

When submitting a dispute, include as much information as you can to help us understand why you think the claim was not paid as you would expect.

How to Submit Provider Disputes

Provider disputes can be submitted in two ways.

      Healthy Blue
      4101 Percival Road
      Columbia, SC 29223

  • Written: Mail the provider dispute form and supporting documentation to:

      Healthy Blue
      Provider Dispute Unit
      Mail Code: AX-570
      PO Box 100317
      Columbia, SC 29202-3317