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Claims Problem Resolution

Typically, there are two types of claim issues:

1. The claim was submitted with incorrect / inaccurate information
2. The claim was processed incorrectly

1. To resolve a claim issue where the claim was submitted with incorrect / inaccurate information, the following options are available:

  • All registered users for clinicians and groups with access to Claim Entry can log in and file a Corrected or Void a claim via the Claim Entry transaction, by choosing "Corrected" or "Void" as the Claim Frequency Code option, and entering the claim number of the original claim (claims must be in a finalized status in order to correct or void them). For additional information, view the Guided Tour documentation, page 24.
  • Fill out a CMS-1500 claim form and write “CORRECTED CLAIM” (or "VOID CLAIM") across the top of the form, and complete the form with the corrected information. Include a copy of the original statement, and mail to the address listed on that statement.

2.To resolve a claim issue where the claim was processed incorrectly, the following options are available:

  • All registered users with access to Claim Inquiry can log in, look up the claim via the Claim Inquiry transaction, and file a Claim Adjustment Request. For additional information, view the Guided Tour video of the Claim Inquiry and Claim Adjustment Request transactions.
  • Contact a claims representative via Provider Express' Live Chat  by either going to the Claim Inquiry page or My Submitted Claims page (if the claim was submitted through Provider Express). 
    • Locate the claim and from the claim detail page, click the link "Have questions about claim status?" to access Claims Live Chat
    • If you cannot locate the claim, then click the "Can't find claim status online?" from the Claim Inquiry page to reach a Claims agent via Live Chat 
  • Call the Customer Service number on the back of the member's insurance card or on the Explanation of Benefits (EOB) / Provider Remittance Advice (PRA).