This article describes functionality on the NaviNet® web portal that is applicable to members who have been migrated to the new platform. As previously communicated, we will transition AmeriHealth New Jersey commercial members to the new claims processing platform between September 1, 2015, and October 1, 2015. During this time, we will be working with you in a dual claims-processing environment until all of our AmeriHealth New Jersey membership is migrated to the new platform.
Reminder: When conducting transactions from AmeriHealth NaviNet Plan Central, search results will include information only for members covered under AmeriHealth plans. Please ensure you have access to all applicable health plans you do business with.
EOB and Remittance
Once a member has been migrated to the new platform, participating providers can use the EOB and Remittance transaction to get claim payment information for finalized claims processed on the new platform. Through this transaction, providers can download and/or print their Provider Explanation of Benefits (EOB) (for professional providers) or Provider Remittance (for facility providers) for migrated members. Providers can also search for statements in two-week increments. Up to four months of historical remittance data will be stored at a time, so it is important to download and save reports on a regular basis.
Provider EOB and Provider Remittance statements will include Accounts Receivable (A/R) detail, when appropriate, and may contain multiple PDF documents. The various payment types include spending account payment, remittance payment, and facility remittance.
To access the EOB and Remittance transaction, select ePayment from the AmeriHealth Workflows menu, and then EOB and Remittance. To help you interpret your Provider EOB or Provider Remittance, we have published guides that are available in the Claims Submission and Payment section of our System and Process Changes site. Note: Your designated NaviNet Security Officer has access to the transaction, and he or she will manage access for applicable staff.
For claims with service dates that span migration
Providers currently enrolled for the Online Statement of Remittance (SOR) will continue to have access to remittance data for claims processed on the old platform (i.e., for AmeriHealth New Jersey commercial members who have not yet been migrated to the new platform). When the claim service date range spans migration (i.e., dates of service prior to and post member migration), providers can expect the following:
- Facility claims. If the date of admission occurred prior to the member?s migration to the new platform, the claim will be processed on the old platform and resulting remittance data will be available through the Online SOR transaction. If the date of admission occurred after the member was migrated to the new platform, the claim will be processed on the new platform and the resulting remittance data will be available through the EOB and Remittance transaction.
- Professional claims:
- If the date of service is before the member is migrated to the new platform: The claim will be processed on the old platform, and the resulting remittance data will be available through the Online SOR transaction.
- If the date of service is after the member is migrated to the new platform: The claim will be processed on the new platform, and the resulting remittance data will be available through the EOB and Remittance transaction.
- If dates of service include dates both pre- and post-member migration: The claim will be split. For dates of service prior to member migration, the specified service lines will be processed on the old platform, and the resulting remittance data will be available through the Online SOR transaction. For dates of service after member migration, the specified service lines will be processed on the new platform, and the resulting remittance data will be available through the EOB and Remittance transaction.
Claims Investigation
For finalized claims processed on the old platform (i.e., for non-migrated members), providers can submit an adjustment for an individual claim using the Claims Investigation link within the Claims Status Inquiry transaction. Through this link, providers are able to edit the claim (including the ability to submit late charges).
As AmeriHealth New Jersey commercial members are migrated to the new platform, this functionality will change. For finalized claims processed on the new platform (i.e., for migrated members), providers will be offered the Claim Investigation Inquiry transaction. The transaction allows providers to submit an adjustment for an individual claim and will permit limited claim editing (excluding the ability to submit late charges). When initiating an adjustment, you will be requested to select one of the following Adjustment Types:
After selecting the Adjustment Type, proceed to the provided text box to indicate the details of your request. Individual claim service lines will no longer be provided, and your contact information and telephone number continue to be required fields. You will receive a response message after submitting your adjustment; however, a unique adjustment ID will not be assigned. If you need to add late charges or make other significant changes to the original claim, you will need to submit a corrected claim through your normal claim processing channels.
Reminder: To check the status of a previously submitted adjustment request, use the Claims Investigation Inquiry transaction. After selecting your provider group, complete the Request Date To and Request Date From fields. Please note that the Request Date To will default to today?s date, and the Request Date From will default to 30 days prior to the current date. You can modify these dates, but the date span cannot exceed one month. Up to 18 months of historical data will be available to you. Other optional fields are also available for the Adjustment ID or Investigation Status (open/closed).
Cap Rosters
Updated Cap Roster transactions were introduced in December 2013. Note: If you are enabled for electronic funds transfer (EFT), you will no longer receive paper rosters/reports for AmeriHealth New Jersey commercial members once they are migrated to the new platform.
For more information
We encourage you to review the user guides available in the NaviNet Transaction Changes section of our System and Process Changes site. They describe these transactions in greater detail, including functionality for migrated member claims.
If you have any questions regarding NaviNet transaction functionality, please call the eBusiness Hotline at 215-640-7410 for AmeriHealth Pennsylvania and at 609-662-2565 for AmeriHealth New Jersey.
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