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In recent months, we have communicated information about several new transactions being introduced to AmeriHealth-participating providers on the NaviNet web portal, including NaviNet Claim Investigation, Eligibility and Benefits Inquiry, and Document Exchange. New user guides are now available for these transactions, and we strongly encourage you to review them to become more familiar with the updates.

NaviNet Claim Investigation

The Claim Investigation transaction offered through the NaviNet provider portal allows you to submit a request for claim review for claims that have been finalized by the health plan. You can then view responses to your questions using the Claim Investigation Inquiry transaction. As a reminder, as of May 2013, participating providers are required to use the Claim Investigation transaction to submit claim inquiries. Note: Providers can continue to submit corrected claims electronically or manually through paper.

A few items to note:

• Ensure that you have access to the portal and understand how to utilize the transaction.
• We will continue to redirect those providers who submit paper claim review requests to the portal to initiate the claim review.
• Please be specific when describing the reason for the claim review. Note: A number of providers are submitting claim review requests for lack of referral or authorization. If a claim denied for lack of referral or authorization and one was required, you must submit a valid referral or authorization number in order for the claim to be reconsidered. The submission of medical records as a replacement for a required authorization or referral is not valid.
• For claims processed on our legacy system (pre-migration), you can edit the claim and submit late charges.
• For claims processed on our new system (post-migration), you cannot edit the claim or submit late charges.

If you have a large volume of claim review requests to submit for the same issue, please contact your Provider Partnership Associate or Network Coordinator to discuss before submitting multiple claim review requests through the portal.

A user guide for the Claim Investigation transaction is available in the NaviNet Resources section of our Provider News Center. If you have questions about submitting a claim investigation or inquiry about a previously submitted investigation, please contact the eBusiness Hotline at at 609-662-2565 for AmeriHealth New Jersey or at 215-640-7410 for AmeriHealth Pennsylvania.

Eligibility and Benefits Inquiry

As previously communicated, the new Eligibility and Benefits Inquiry transaction was released last month. The new transaction allows you to search for a member's eligibility and benefits record for up to two years preceding the current date. However, please remember that initially you can only retroactively search for dates of service on or after October 1, 2015. Eligibility and benefits information for AmeriHealth members will not be available through NaviNet for dates of service prior to October 1, 2015.

We have identified some gaps in benefit information with the new transaction. Should you require information on these benefits, please contact Customer Service at 1-888-YOUR-AH1 for AmeriHealth New Jersey or at 1-800-275-2583 for AmeriHealth Pennsylvania. A user guide for the new Eligibility and Benefits Inquiry transaction is available in the NaviNet Resources section of our Provider News Center. For additional information, please review the webinar for this new transaction.

Document Exchange

On August 19, 2016, Document Exchange was introduced to providers on NaviNet. This new feature allows us to share more information electronically with our provider network.

Your designated NaviNet Security Officer controls which end users, including himself or herself, associated with your NaviNet office will be given access to the following five unique Practice Document Categories:

• Billing/Financial Report
• Patient Roster Report
• Patient Transition Report
• Pharmacy Report
• Program Enrollment Report

Once end users are granted permission to access a specific Practice Document Category, they will be able to view and download any documents associated with that category. For example, if a NaviNet Security Officer grants an associate access to the Billing/Financial Reports category, all reports made available by AmeriHealth under that category will be available to the associate to view or download.

It is important for your NaviNet Security Officer to manage permissions appropriately for each document category to ensure reports are accessed in a manner that is compliant with role-based access requirements of the Health Insurance Portability and Accountability Act (HIPAA).

Note: Third-party vendors that have access to NaviNet will not have the ability to access Document Exchange.

Initial report

The High Risk Hospitalization Predictor report from August 2016 is available for targeted primary care physician practices under Document Exchange in the Patient Roster Report category. Based on a predictive model, this report identifies members you have treated who are at high risk of acute hospitalization in the next six months and who have one or more of the following chronic conditions:

• chronic obstructive pulmonary disease (COPD)
• congestive heart failure (CHF)
• coronary artery disease (CAD)
• diabetes

If you have questions or suggestions that relate to the High Risk Hospitalization Predictor report, please contact your network medical director.

For detailed instructions on how to use Document Exchange, review the user guide, which is available in the NaviNet Resources section of our Provider News Center. If you have any questions about Document Exchange, call the eBusiness Hotline at 609-662-2565 for AmeriHealth New Jersey or at 215-640-7410 for AmeriHealth Pennsylvania.

NaviNet is a registered trademark of NaviNet, Inc.

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