Provider Inquiry Tip Sheet

Purpose of the Provider Inquiry and Provider Inquiry transaction
Provider Inquiry completely replaces a paper-based Provider Claim Inquiry Form that allows a user to submit claim adjustments and other inquiries on-line.

Note: This transaction is currently only accepted by Highmark BlueCross BlueShield of Western New York and Highmark BlueShield of Northeastern New York

*For more detailed information on this transaction, please link to the user guide here: PROVIDER-INQUIRY-USER-GUIDE

CHANGES EFFECTIVE 12/1/2021. For more detailed information, please link to the updates here: Highmark BCBSWNY & BSNENY Provider Inquiry

Completing the Provider Inquiry Form:

Indicate Payer (Required)
Select payer from the drop-down list.

Provider Information
Required:

Patient Information
Required:

Optional:

Claim Information
Required:

Optional: If you do not enter the required information, the submit button will be 'greyed' out until all required fields are entered.

Once the submit button is hit and the inquiry has been successfully been received by the Payer, you will receive a pop-up message indicating the Inquiry #

Provider Inquiry Summary Form
Previously submitted inquiries can be viewed on the Provider Inquiry Summary page. You can search for inquiries by selecting search options and filters.

Indicate Payer (Required)
Select payer from the drop-down list.

Provider Information
Required:

Inquiry Date Range
Required:

Filter Options
Optional:

If you do not enter the required information, the submit button will be 'greyed' out until all required fields are entered.

Provider Inquiry Summary Response
If there are more than one(1) Provider Inquiries that fall within the designated time-frame and selected filters, the user will be presented with a list of inquiries to select from. To view the detail of an inquiry, simply click on that inquiry. If there is only one(1) inquiry that meets the submitted criteria, that inquiry will immediately be displayed on the users screen.

The information displayed will include all the information from the original inquiry submission, and if the inquiry is 'Closed', the determination message from the payer.

Inquiries have two statuses, PENDED and CLOSED.

Pended inquiries are still open and do not have a final determination.

Closed inquiries have a final determination and will have that information in the "Payer Messages" section on the inquiry.

Appendix A
Inquiry Type Description Attachment Required?
Claim Status Used to inquire on the status of a claim when it is showing in a pended state or if there is a question regarding how the claim was processed. Co-pay/Co-Insurance/Deductible Inquiry. Paid incorrect Fee Schedule / Rate Inquiry NO
Billed Amount Used when requesting an adjustment to correct an amount billed on a claim. NO
Change Units Used when requesting an adjustment to the number of units billed for a specific procedure. YES
Date of Service Used when requesting an adjustment to correct the date of service billed on a claim. NO
Diagnosis Code Change Used when requesting an adjustment to correct a diagnosis code billed on a claim. NO
Place of Service Used when requesting an adjustment to correct the place of service on a claim. NO
Procedure Code Used when requesting an adjustment to correct the procedure code billed on a claim. NO
Provider ID Used when requesting an adjustment to correct the provider ID used on a claim. NO
System Updates Used when requesting an adjustment after updates have been made to a member's file (PCP change, Referrals, Authorizations, etc.) YES
Valid Online Relationship Used when requesting an adjustment on a claim for a covering provider that denied or processed out-of-network in error. YES
Withdraw Payment Used when requesting an adjustment to withdraw a claim that was billed/processed in error. NO
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