Claim Investigation

Health Plans: 

  • West Virginia Family Health

Workflow: 

  • Claim Investigation

Claim Investigation is available for NaviNet's Professional and Facility users. Submit claim investigations for adjustments only.

Submit a Claim Investigation

  1. Sign in to NaviNet. On the Health Plans menu, choose your health plan.
  2. Under Workflows For This Plan, click Claim Status Inquiry, and then find your claim.
  3. Start an investigation from one of the following screens: 
    • On the Claim Status Results screen, click Claim Investigation in the last column.
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    • On the Claim Details screen, above the status bar, click Claim Investigation.
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  4. In the Investigation pop-up window, choose an investigation type, and then type your comments for the investigation reviewers. 
    • Claim investigations are per claim, not per line item. To reference a specific claim line, provide the line number in the Comments box. 
    • If the adjustment reason is the same for multiple claims, you can reference multiple claims from one investigation. For example, if the health plan denied five claims for Coordination of Benefits, start an investigation on one of the claims, and list the other four claim numbers in the Comments box.
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  5. In the remaining boxes, type your contact information so that customer service can contact you, if necessary.
  6. Click Submit. A pop-up window confirms that the investigation was submitted. 
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To check the status of your investigation after you submit it, click Claim Investigation Inquiry under Workflows For This Plan on the Plan Central screen.

View an Existing Investigation

  1. Sign in to NaviNet. On the Health Plans menu, choose your health plan. 
  2. Under Workflows For This Plan, click Claim Investigation Inquiry.
  3. Enter the following required search criteria, and then click Search.
    • Billing provider
    • Request from and to date (Enter a date up to seven years in the past. The date range cannot exceed one month.)
    • (Optional) To narrow your search further, select an investigation status of Open or Closed.
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  4. If your search returns multiple results, the Search Results screen appears. Click anywhere in a row to select the desired investigation.
    • To modify your search criteria, use the Wayfinder to return to the Search screen.
    • Click the up and down arrow icons in any column to sort the results.
    • A status of Closed indicates that responses have been received from the reviewers.
      ImageIf your search returns only one request, the detail screen appears for that request.
  5. View the investigation details. The screen displays the original investigation comments and the reviewer’s response, if available. Comments and responses appear from oldest to newest at the bottom of the page.
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If you submit an investigation without the necessary information, West Virginia Family Health cannot complete your adjustment request. They will respond to the investigation and will note the missing information. You can provide the requested information from Claim Investigation Inquiry by clicking Claim Investigation

Follow Up on a Previous Investigation

After you view the investigation comments and replies in the Claim Investigation screen, you can submit a follow-up comment or question if necessary.

  1. In the Actions section, click Claim Investigation.
  2. On the Investigation pop-up window, enter further comments or questions. Follow Up to Previous Investigation is the only valid investigation type.
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    If you submit a follow-up comment, the reviewer will see your comment with all of the other comments that you previously entered.

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