Claim Status Inquiry transaction

As previously communicated, we will be introducing a new Claim Status Inquiry transaction on the NaviNet web portal.

Access to the new transaction will be made available for all providers on Friday, January 20, 2017.

The transaction has been updated with a brand-new look and will continue to provide you with real-time access to detailed claim information. Some of the enhanced features include:

• New search criteria that allows you to search for claims using the member ID or member name and date of birth.
• A new filter that allows you to narrow your claim search by claim identification number.
• A new hover feature on the Claim Detail screen that allows you to access additional claim information.

Please note that the new transaction will not provide access to claims processed on our legacy platform (i.e., pre-migrated claims). New Claim Investigation requests for pre-migrated claim submissions will not be supported.

Should you need to submit a claim review request for a finalized claim, a link to the Claim Investigation transaction will continue to be available on the Claim Search Summary and Claim Detail screens.

The user guide for the Claim Status Inquiry transaction is available in the NaviNet Resources section. If you have questions about the new transaction, please contact the eBusiness Hotline at 215-640-7410.

Updated Claim Investigation Submission Guide

The Claim Investigation transaction offered through NaviNet 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 inquires. 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 either submit paper claim review requests or call customer service to the portal to initiate a 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 is 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 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 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. If you have questions about submitting a claim investigation or inquiry about a previously submitted investigation, please contact the eBusiness Hotline at 215-640-7410.

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