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).