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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:

  • In-network clinicians and groups can log in and file a Corrected or Void 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:

  • In-network clinicians and groups 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.
  • Access the Claim Inquiry/Adjustment Request Form and mail it to the address listed on the EOB/PRA form.
  • Contact a claims representative via Provider Express's Live Chat (for registered users) by logging in and going to Claim Inquiry (or My Submitted Claims, if the claim was submitted online). 
    • Locate the claim and towards the upper right on either "detail" page (above the member's ID #), 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?" link on the main Claim Inquiry page (see screenshot for location).

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).