All participating providers (including third-party administrators supporting
the organization) are required to have access to the NaviNet®
web portal. In addition, all participating providers are required to use
NaviNet for specific
activities, including:
- Verifying member eligibility. The Eligibility and Benefits Inquiry
transaction provides you with detailed information
relating to our members' eligibility.
- Checking claim status. The Claim Status Inquiry transaction allows
you to view the progress of your accepted
claim submission. You can view claims with service dates up to 18 months in the
past. The claim detail includes
specific information, such as check date, service codes, paid amount, and
member responsibility.
- Submitting claim adjustments. Providers who are looking to request a
claim review must submit those requests
through the Claim Investigation transaction. A link to Claim Investigation can
be found when searching for a specific
claim through Claim Status Inquiry.
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 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 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, however, you are experiencing an issue that affects a significant number of
claims, we recommend that you contact your Provider Partnership Associate or
Network Coordinator for assistance rather than submit an adjustment request
through NaviNet.
New Claim Status Inquiry transaction coming soon
In December 2016, we will be introducing our new Claim Status Inquiry
transaction. The updated transaction will continue to provide you with
access to real-time, detailed claims information and indicate whether
claims were submitted electronically or on paper.
A new user guide for Claim Status Inquiry will be published prior to the
release of this updated transaction. Announcements will be posted on
AmeriHealth NaviNet Plan Central and on our Provider News Center
once the new guide is available.
If you have any questions about using NaviNet or these provider self-service
requirements, please call the eBusiness
hotline at 609-662-2565 for AmeriHealth New Jersey or at
215-640-7410 for AmeriHealth Pennsylvania. If you are not
yet NaviNet-enabled, go to the NaviNet website to sign up.
NaviNet is a registered trademark of NaviNet, Inc.