Claim Disputes

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Claim Payment Disputes

Claim payment dispute is also called a reconsideration. We are unable to process a reconsideration without a finalized claim on file. 

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. Reconsiderations filed more than 90 days from the Explanation of Payment are considered untimely and denied unless good cause can be established.

Providers will not be penalized for requesting 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.

There are three common, claim-related issues that are not considered claim payment disputes. To avoid confusion with claim payment 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 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.

Required Documentation for Claim Payment Disputes

Healthy Blue requires the following information when submitting a claim payment 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 reconsiderations, 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 Claim Disputes

Claim payment disputes can be submitted in two ways.

  • Verbally: Call Provider Service at 866-757-8286.
  • Written: Mail the provider dispute form and supporting documentation to:

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