This Guide provides instructions on how to submit and retrieve Claim Inquiry Express Requests (ExR).

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1 This Guide provides instructions on how to submit and retrieve Claim Inquiry Express Requests (ExR). Web site users with questions about claims have two ways to submit claim inquiries through the Secure Services provider web site. 1) A user can go to General Claim Inquiry and complete a form called an Express Request by entering all of the details about the claim. 2) Or, go to the Claims & EOP/EOB Look-up tool and by locating a specific claim, select to have an Express Request pre-populated with the claim details they are viewing. There is no limit as to how often a user may submit a Claim Inquiry Express Request; however, each claim inquiry should be submitted separately. Accessing Claim Inquiry Express Request Tools To submit a question about a particular claim which a user has looked up, the user should select the (1.) Claims & EOP/EOB Look-up feature from the main menu ( My Menu ) as appears in the screenshot below. This feature also enables a user to obtain the status of a claim, Explanation of Payment, Explanation of Benefits and/or provider checks/payments. Users who are unable to find a certain claim using this search feature or wish to provide their own details may use the (2.) General Claim Inquiry. Revised February 2009 Page 1 of 6

2 Completing a Claims Inquiry Express Request Question: How do I submit a question about a specific claim? Answer: General Claim Inquiry Users that have a question or disagreement with the amount paid or a denial, or are requesting a cashed check or benefit determination review should use the General Claim Inquiry. 1. From My Menu select General Claim Inquiry from beneath Provider Services, Provider Inquiry. 2. Then click on the blue link that says, 3. You should arrive at this page. You will need to complete this form with all needed information. Required Fields: Question Member Type Patient Name SSN/Member ID Date of Service Service Type Optional Fields: Claim Number Total Charges Questions/Comments (free text field) 4. Once you have completed the form, click one of two action buttons found at the bottom of the page: Immediately sends in your request Allows the user to save the request for completion or submission at a later date 5. You will come to a confirmation screen which will provide a tracking number assigned for your future reference. Be sure to make note of it! Revised February 2009 Page 2 of 6

3 Question: How do I submit a question about a claim I looked up (or don t have the details for)? Answer: Claim Inquiry from Claims & EOP/EOB Look-up Use this type of Express Request to search for and submit an inquiry about a specific claim. Upon locating the claim, you are able to populate much of the inquiry form in a single click. 1. From My Menu select Claims & EOP/EOB Look-up under Provider Services, Provider Inquiry. 2. Three search options are available: 3. Enter the appropriate information and click the Search button located on the bottom right of the information box chosen to view the claim. 4. Once the claim is displayed, click on the link, I have a question about this claim. 5. A Claim Inquiry Express Request form should populate with that claim s details. Enter any additional details into the needed fields (see 3. under Completing a Claims Inquiry Express Request above). 6. Once you have completed the form, scroll to the bottom of the page and click either: or Submit immediately sends in your request and allows you to proceed to step #7. Save allows the user to save the request for completion or submission at a later date. 7. You will come to a confirmation screen which will provide a tracking number assigned for your future reference. Be sure to make note of it! Revised February 2009 Page 3 of 6

4 Retrieving Submitted Express Request Responses There are two ways that a user can check the status of a Claims Inquiry Express Request. Option 1: Click on Express Request near the top of the screen: Option 2: After a user submits a new Express Request, a prompt will appear on the home page. Click on the link for New Express Requests under the Welcome greeting. Once you reach the Express Request Menu page, click on New Replies, the second link beneath Express Request Options. Then select the response via tracking number to view the status of your Express Request. Revised February 2009 Page 4 of 6

5 Appendix A: How to submit an ExR with attachment When opening a new Express Request, an Attachments box appears at the top of the request page. To submit a file with your request, click on Attach Document. Click on Browse to search and select the appropriate file. Additional comments can also be added in the Description text box. After doing so, click on Add to attach the file. The file will be scanned for viruses at this time. If one is detected, the process will reject the file and display a message that the file cannot be attached. The ExR request can still be submitted without the file. If the virus scanner is not available for any reason, the process will display a message that the file cannot be added at this time. If no virus is found, an uploaded successfully message displays, and the ExR request can be submitted. After the ExR request is submitted, the confirmation page with the assigned tracking number will also include the attached file and any comments. Revised February 2009 Page 5 of 6

6 Appendix B: Additional uses for the General Claim Inquiry Express Request General Claim Inquiry may be used to submit other types of non-status-related* Express Requests. This includes: ( ) Submitting a claim for review and reconsideration if you are contesting a reimbursement rate, authorization denial, member eligibility or vendor issue.** **If you are an in-network provider and your payments are going to an incorrect address or your Vendor/Billing address has changed, please complete the Provider Demographic Information Change form located in My Menu under Submit Your Information and fax a completed W-9 with coversheet to (646) , Attn: Portal Request. To determine whether or not your request for review and reconsideration requires documentation, please refer to section 16 of the Provider Manual for examples. Documentation may be submitted via online attachment or by mail. Secure Services now offers users the ability to submit electronic attachments via Express Request. To learn how please refer to Appendix A of this guide. To submit via hard copy, please mail your request to: Healthfirst New York Member Claims: Healthfirst, Inc. Correspondence Unit P.O. Box , Lake Mary, FL Healthfirst NJ Member Claims: Healthfirst NJ Correspondence Unit P.O. Box Newark, NJ ( ) Initiating a request for Overpayment Recovery To do so, you must provide the following information in your Express Request: o Claim Number or Member ID(s) and Date(s) of Service o Provider s full name o Recovery amount o Reason for the recovery There are various reasons that a provider may need to file such a request. These may include: o Duplicate payment o Other insurance paid primary o Billed wrong member ID, wrong date of service or in error o Paid incorrect provider or incorrect provider ID Our goal is to complete all requests within 3 business days. However, the Claims department has 30 days in which to do so. Some requests require additional time, such as inpatient claims review. For more details refer to section 16 of the Provider Manual available under Provider Information/Policies & Procedures. Find further instruction in the Reference Guide under the Website Resource Center. *To check the status of a particular claim, please use the Claims & EOP/EOB Look-up tool. Revised February 2009 Page 6 of 6