Enhanced Claim Status Workflow

Health Plans: 

  • Horizon BCBSNJ

Workflow: 

  • Claim Status

You can now use the NaviNet Open Claim Status workflow when you search for a claim. You can also attach documents to a claim to appeal the claim or send more details to Horizon.

About this New Feature guide

This new feature guide represents the NaviNet Open Claim Status implementation for Horizon BCBSNJ. This new feature guide is not meant to be a user guide. For complete details, see the NaviNet Open Claim Status user guide.

Open Claim Status Inquiry workflow

You can access the new NaviNet Open Claim Status Inquiry workflow under Workflows for This Plan on the Horizon BCBSNJ Plan Central screen.

  1. Sign in to NaviNet. On the Workflows menu, select My Health Plans, and then click Horizon BCBSNJ
  2. Under Workflows for this Plan, select Claim Management > Claim Status Inquiry.
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  3. On the Claim Status: Search screen enter your search criteria:
    1. A local search is turned on by default. To search for an out of area claim, select the Out of Area tab.ImageImage
    2. Select a provider by typing a name or ID into the Billing Entity field.
    3. For out of area claim searches, indicate whether the patient is the Subscriber or Dependent by clicking the corresponding radio button.
    4. Enter the patient's date of birth in the Date of Birth field. Use the format, "mm/dd/yyyy."
    5. For Local claim searches, you can search by Member ID, or by first and last name. Either Member ID or Last Name and First Name are required. If you are performing an out of area claim search, all three fields are required.
    6. For out-of-area dependents, you must also enter the Subscriber's Last Name.
    7. Enter the Service Start and Service End dates for the claim. You can search for service start and end dates with a maximum range of 90 days. Up to 18 months of claims history is available.
    8. Optionally, enter a Claim ID.
  4. Click Search.
  5. If only one claim matches your search, the Claim Status Details screen appears and you can proceed to the next step. If more than one claim matches your search, the Claim Status Search Results screen appears. On the Claim Status Search Results screen, you can either:
    • Select the desired Claim ID to access the Claim Status Details screen.
    • Click Back to Claim Status Search in the Wayfinder to modify your search criteria.
    • If an EOP link is available for a claim, click the link to view payment details for the claim. The EOP link appears next to the claim's status when it is available.
  6. On the Claim Status Details screen, you can review the details of the claim. You can also take the following actions:
    • Point to a service line to click View Additional Detail. The health plan provides additional details (such as additional payment information) in the pop-up window when details are available.
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    • On the toolbar located above the status bar, click Attach to attach one or more documents to the claim, or click the View/Print link to print the contents of the screen.
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Add an attachment

You can appeal or send more information about a claim to Horizon by attaching one or more documents to the claim and selecting the appropriate Document Type. You can attach documents to any Horizon claim. Horizon supports the following file types: JPEG, JPG, TIFF, and PDF. The file size limit is 15 MB.

  1. On the Claim Status Details screen, above the status bar, click Attach. The Attach Documents pop-up window appears.
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  2. You can either drag and drop a document into the middle of the pop-up window or click Add Document to browse for and select a document with windows explorer. 
  3. Once you have selected a document to attach, select the Document Type from the drop-down menu. You can select from any of the following document types. To appeal a claim, select one of the  "Plan's Claim Appeal Form" document types.
    • Ambulance Report
    • Anesthesia Record
    • Complete Medical Record
    • COB Questionnaire
    • Consultant / Consultation Report
    • DME Order / Letter of Medical Necessity
    • Physician / Nursing / Office Notes
    • Discharge Summary
    • Emergency Room Report
    • History and Physical
    • Laboratory Report
    • Medication Record
    • Letter/Form of Medical Necessity
    • Occupational, Physical or Speech Therapy Progress Notes
    • Operative Report
    • Psychiatric Assessment/ Evaluation
    • Psychiatric Progress Notes
    • Photos / X-Rays
    • Psychiatric Team Conference Notes
    • Prescriptions/Orders
    • Pathology Report
    • Entire Psychiatric Record with the exception of Psychotherapy Notes
    • Radiology Report
    • Substance Abuse Record with the exception of Substance Abuse Therapy Notes
    • Sleep Study Report
    • Occupational, Physical or Speech Therapy Report
    • Psychological Testing
    • Treatment Plan
    • Plan's Claim Appeal Form - Allowance - Provider/Member Letter
    • Plan's Claim Appeal Form - Allowance - Plan's Claim Appeal Form
    • Plan's Claim Appeal Form - Allowance - Medical Record
    • Plan's Claim Appeal Form - Allowance - Remittance Allowance
    • Plan's Claim Appeal Form - Allowance - Explanation of Benefits or Explanation of Medicare Benefits
    • Plan's Claim Appeal Form - Allowance - Member Authorization
    • Plan's Claim Appeal Form - Benefit Denial - Provider/Member Letter
    • Plan's Claim Appeal Form - Benefit Denial - Plan's Claim Appeal Form
    • Plan's Claim Appeal Form - Benefit Denial - Medical Record
    • Plan's Claim Appeal Form - Benefit Denial - Remittance Allowance
    • Plan's Claim Appeal Form - Benefit Denial - Explanation of Benefits or Explanation of Medicare Benefits
    • Plan's Claim Appeal Form - Benefit Denial - Member Authorization
    • Plan's Claim Appeal Form - Claim Payment - Provider/Member Letter
    • Plan's Claim Appeal Form - Claim Payment - Plan's Claim Appeal Form
    • Plan's Claim Appeal Form - Claim Payment - Medical Record
    • Plan's Claim Appeal Form - Claim Payment - Remittance Allowance
    • Plan's Claim Appeal Form - Claim Payment - Explanation of Benefits or Explanation of Medicare Benefits
    • Plan's Claim Appeal Form - Claim Payment - Member Authorization
    • Plan's Claim Appeal Form - Medical Necessity - Provider/Member Letter
    • Plan's Claim Appeal Form - Medical Necessity - Plan's Claim Appeal Form
    • Plan's Claim Appeal Form - Medical Necessity - Medical Record
    • Plan's Claim Appeal Form - Medical Necessity - Remittance Allowance
    • Plan's Claim Appeal Form - Medical Necessity - Explanation of Benefits or Explanation of Medicare Benefits
    • Plan's Claim Appeal Form - Medical Necessity - Member Authorization
  4. You can remove a document you selected before attaching it by pointing to the entry and clicking Delete
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  5. When you are finished adding documents, click AttachA pop-up message appears on the bottom right of the screen indicating that the selected files were uploaded successfully.
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