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In recent months, we have communicated information about several new
transactions being introduced to
Independence-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 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 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 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 215-640-7410.
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 July 1, 2015. Eligibility and benefits information
for Independence members will not be available through NaviNet
for dates of service prior to July 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 1-800-ASK-BLUE. 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
Independence 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
215-640-7410.
NaviNet is a registered trademark of NaviNet, Inc., an
independent company.
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