Electronic Claims (Submission, Status, and Inquiry)

Highmark uses Availity Essentials, a secure, full-service web portal that offers electronic solutions at no charge for providers to perform essential claim processes.

If your organization is not already registered with Availity, visit the Register and Get Started with Availity Essentials webpage.

More information about all the following processes may be found in Highmark’s Provider Manual.

• Submit a Claim
• Check Claim Status
• Claim Inquiry

Submit a Claim

Submit electronic claims to Highmark in one of the following ways:

Availity Essentials

Availity Essentials functions as a multi-payer provider platform offering user-friendly online tools for healthcare providers. You must be registered with Availity to use the Claim Submission for electronic claims.

• Help
  • In the Availity Essentials navigation bar, select Help & Training | Find Help. Search by keywords such as claims and encounters or professional claim. Or, go directly to the Claims & Encounters help topics.
• Training
  • In the Availity Essentials navigation bar, select Help & Training > Get Trained. Search for “Claim Submission for Highmark Providers."
• Support
  • In the Availity Essentials navigation bar, select Help & Training > Availity Support. Or, call 800-282-4548 (800-AVAILITY).
  • Tip: See the Availity Client Services help topic for more information.

Electronic Data Interchange (EDI)

Providers who are interested in integrating real-time capabilities within their practice management system should discuss this functionality with their software vendors and review Highmark’s EDI website.

Choose the applicable link below to review our EDI transaction and connectivity specifications in the Resources section of the website:

• Delaware: https://edi.highmark.com/edi-bcbsde/index.shtml
  
• New York: https://www.ask-edi.com/
• Pennsylvania: https://edi.highmark.com/edi/index.shtml
• West Virginia: https://edi.highmark.com/edi-wv/index.shtml

Claim Status

There are two ways to check the status of your claim.

Availity Essentials

The Claim Status function in Availity allows you to view real-time, detailed claims information for any Highmark member, whether claims were submitted electronically or on paper. You can track the status of a claim from the start of the adjudication process until the time of payment.

• Access the Claim Status function under Claims & Payments in the Availity main website menu to search for claims or view a claim status.
• A demo video is available to assist you in the process. You can find the video in the top right-hand corner of the screen.
• Additional training information can be found under Help & Training.

Interactive Voice Response (IVR):

Our automated telephone system is available 24 hours a day, 7 days a week.

• Call the Provider Service Center
  • Be prepared with the provider’s NPI number; member’s Highmark ID or social security number; member birthdate; and date of service.
• You can access the following claim information:
  • Charges
  • Process date
  • Member responsibility
  • Who claim is paid
  • Claim number
  • Number of charges on claim
  • Provider responsibilities
  • Paid amount.

Claim Inquiries

Submitting claim inquiries via Availity is required for all providers in Delaware, Pennsylvania, and West Virginia.

• How to Submit a Claim Inquiry in Availity

More information about claim inquires may be found in Highmark’s Provider Manual, Chapter 6, Unit 1