We are pleased to introduce a new article series to provide tips on how to use certain transactions on the NaviNet web portal.

When using the Claim Investigation Submission transaction, please be specific when describing the reason for the claim review. Note: You must first perform a Claim Status Inquiry to locate the claim. A detailed user guide is available in the NaviNet Resources section.

Follow the tips below to ensure that claim investigations are responded to promptly.

Submission preparation

Prior to submitting a general claim investigation, take the following steps:

• Using the Claim Investigation Inquiry transaction, confirm that there is not an existing investigation for the same claim.
• Verify the line of business (LOB) for the member?s benefit plan, the member?s coverage effective date compared to date of service, and the member?s eligibility for the service(s) performed.
• Review your AmeriHealth Agreement effective date and expected reimbursement.
• Verify the status of the authorization, if applicable (i.e., pending vs. approved, dates of service, and service(s) performed).
• Confirm the diagnosis code was billed to the highest specificity.

Inquiry submission

Claim investigation submissions should be specific. Include the following information, where applicable:

• the procedure code in question;
• the claim line in question;
• whether you suspect an overpayment, underpayment, or incorrect denial;
• detail on how you calculated payment to determine if it is an overpayment/underpayment or specific medical or claim payment policy to support amended claim payment for denied service(s);
• expected reimbursement rate;
• provisions in your Agreement that could/would affect reimbursement;
• an authorization or referral number, as applicable.

Look for additional articles in this series of NaviNet tips for more successful inquiry submissions.

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