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Treatment plans may be required for certain specialty services such as physical therapy, mental health, substance abuse treatment, etc. Providers will ensure their medical documentation has the correct service and diagnoses that refect their claim submissions. Claims Resolution Priority Partners is dedicated to providing timely resolution of claims. When billing codes are updated, providers are required to use appropriate replacement codes for submitted claims. Priority Partners uses code editing software to determine which services are considered part of, incidental to, or inclusive of the primary procedure. Timely fling periods begin from the date of discharge for inpatient services and from date of service for outpatient/physician services. Together, they provide specifc information regarding the review and interpretation of the Priority Partners Remittance Advice. Tus, there may be sections that are not applicable for posting and reconciliation of certain claims. Payee The name and address of the payee as indicated on the submitted claim Check Date The date the check (if any) was prepared. Billed Amount The amount identifed by the provider as a charge for a service or procedure. Charges Above Max The portion of the billed amount that is in excess of the established fee maximum for the procedure. It may represent that portion of the charge above the beneft maximum (and would not be a members liability) and/or the charge for a non-covered procedure (which would be a members liability). Deduct/Copay/ Identifes the members liability for cost-sharing features (deductible, Coinsurance copayment and/ or coinsurance) of the program. Other Insurance Paid The total dollar amount paid by any other insurance carrier or Medicare. Subscriber Liability The dollar amount which the provider may collect from the subscriber. This amount includes any applicable deductible, copayment, coinsurance and charges for non covered services. The allowed amount minus deductible/copayment/coinsurance minus other insurance paid equals the net payable. Remark Code The code number that identifes a message to the provider regarding payment of the claim. Provider Name The name of the provider who provided services for a submitted claim. Line of Business The code indicating in which line of business the patient is a member.
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