We continue to share tips to help providers and their administrative staff prepare for the upcoming
self-service requirements that begin
January 1, 2022. PEAR Practice Management (PM) offers transactions that can be used daily by your practice to provide efficient patient care.
TIP #5: Submission requirements
Follow these guidelines when requesting a claim investigation:
- The claim must be in a
finalized state to request an investigation.
- Claim investigation submissions are permitted within 18 months from the date of service.
- A maximum of
three inquiries can be submitted per claim.
- Claim investigation requests are not available to Independence Administrators.
- Before submitting an investigation, use the Claim Investigation Search transaction to confirm that an investigation is not already open for your claim.
- Be specific when describing the reason for the investigation. If a claim is denied for lack of referral or authorization and one was required, you must submit a valid referral or authorization number for the claim to be reconsidered. The submission of medical records as a replacement for a required authorization or referral is not valid.
Review the Claim Search & Investigation user guide and eLearning course on the
PEAR Help Center.
TIP #6: Navigating the Claim Search transaction
Claim Search from the Transactions tab and follow the steps to locate the claim in question.
Once on the Claim Details screen, select the
Create New Investigation button to start a new investigation.
Follow the steps outlined in the Claim Search & Investigation user guide on the
PEAR Help Center to complete your submission.
TIP #7: Claim investigations for Out-of-Area or FEP members
Providers should call Provider Services at 1-800-ASK-BLUE (1-800-275-2583) for claim questions about out-of-area BlueCard® members.
For Federal Employee Program (FEP) members, CMS-1500 claims are sent directly to Highmark for processing. Therefore, you will need to submit a claim investigation through Highmark NaviNet® Open Plan Central or call their customer service team at 1-866-731-8080.
Facility claims can be located through the Claim Search transaction by using the FEP member ID or claim ID.
NaviNet® is a registered trademark of NantHealth, an independent company.