HIPAA claim investigation

HIPAA Claim Investigation (Highmark)

HIPAA claim investigation is the ordinary means providers use to communicate their questions regarding pending, paid, or denied claims. An investigation should be submitted if the provider has a question about the status of a claim. Complete research should be completed by the provider prior to submitting the investigation. A claim investigation is appropriate if any of the atypical situations listed below occurs:

  • A claim has been pending for more than forty-five (45) days beyond the received date
  • A claim has been paid, but the facility questions the payment amount
  • A claim is denied and the facility questions the denial reason Claim investigations can be launched from NaviNet® Claim Status Inquiry or through the 276/277 Health Care Claim Status Request and Response transactions.

HIPAA claim investigation is available for NaviNet’s professional and facility users in two areas within Claim Status Inquiry:

  • Search Results and
  • Claim Status Details. The claim number and patient name will be displayed on the claim investigation screen. Select the Investigation Type from the choices in the dropdown, and then enter pertinent information in the Comments box. Highmark needs enough information to readily address your request about the claim in question. Complete the Contact fields, and then click Submit. An informational page confirms that the investigation was submitted.

IMPORTANT! Please include contact information for Highmark to reach the appropriate person if additional information is needed. You can check the status of an investigation by using NaviNet’s Claim Investigation Inquiry under Workflows for this Plan on Highmark Plan Central.

NaviNet User Guides are available for help when submitting claim investigations. To access User Guides for both professional and facility providers, select Help from the toolbar, and then select the applicable Highmark option for your service area. These guides provide more detailed instructions for claim investigation submission, including an Investigation Type Reference Table that provides the minimum amount of information you must include in the Comments box for each investigation type. Claim investigations can also be done using the 276/277 Health Care Claim Status Request and Response electronic transactions.

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