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 Network Coordinator for assistance rather than submit an adjustment request through NaviNet.

If you have any questions about using NaviNet or these provider self-service requirements, please call the eBusiness hotline at 215-640-7410. If you are not yet NaviNet-enabled, go to the NaviNet website to sign up.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.