Provider Dispute Process
The provider dispute system will be the sole remedy to dispute the denial of payment of a claim or, in the case of a contracted, in-network provider, to dispute the contractor’s policies, procedures, rates, contract disputes or any aspect of the contractor’s administrative functions.
We accept provider dispute requests in writing, verbally, in-person and via email. Claims-related provider disputes filed more than 90 days from the remittance are considered untimely and denied unless good cause can be established. For disputes not involving a remit, you may submit at any time.
Providers will not be penalized for requesting a dispute, nor is there any action required by the member. 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.
Note: Healthy Blue no longer considers claims that exceed the timely filing limits due to the provider being unaware of a member’s coverage.
What to do Before Submitting a Claims- Related Provider Dispute
Before submitting a claims-related 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 Dispute
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 a Provider Dispute
Provider disputes can be submitted in four ways.
- Verbally: Call Provider Service at 866-757-8286.
- Email: Send the provider dispute form and supporting documentation to HBProviderService@HealthyBlueSC.com
- In Person: Speak with someone by visiting:
4101 Percival Road
Columbia, SC 29229
- Written: Mail the provider dispute form and supporting documentation to:
Attn: Healthy Blue
PO Box 100317
Columbia, SC 29202-3317