When using the Claim Investigation Submission transaction on the NaviNet web portal, 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 guidelines below to ensure that claim investigations are responded to promptly.

Submission preparation

Prior to submitting a general claim review request, 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 Independence 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.

Our user guide will be updated to reflect these guidelines.

Look for additional articles outlining best practices when using certain transactions on NaviNet.

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