Claims submissions and disputes

Providers may enter all claims submissions and requests through Availity Essentials or using electronic data interchange (EDI) for a centralized and easy-to-use experience.

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Submitting claims through EDI

Providers may submit claims, eligibility inquiries, claim status inquiries, and associated attachments using electronic data interchange (EDI) through an authorized trading partner.

EDI lets you:

  • Process claims faster by submitting coordination of benefits electronically and fixing errors early with in-system notification and correction
  • Reduce overhead and administrative costs by eliminating paper claim submissions

Note: All electronic data interchange (EDI) transmissions for Ohio Medicaid Managed Care membership must be submitted to the Ohio Department of Medicaid (ODM).

Submit and check authorization and claims status through Availity* Essentials

Anthem Blue Cross and Blue Shield (Anthem) uses Availity Essentials, a secure, full-service website that allows providers to submit, view, and check authorization and claims status, submit a claim dispute, and clinical appeals.

Don’t have an Availity Essentials account?

Finding claims tools on Availity Essentials

Claims status inquiry:

  1. From the Availity Essentials home page, select Claims & Payments from the top navigation.
  2. Select Claim Status Inquiry from the drop-down menu.

Claims payment disputes and appeals

To file a claim dispute or appeal:

​Providers who disagree with the outcome of a claim can dispute that outcome when the claim is finalized. The payment dispute process consists of two steps. Providers will not be penalized for filing a claim payment dispute:

  1. Submit a first-level claim payment dispute. This is the provider’s initial request for a review into the outcome of a claim once it is finalized.
  2. Submit a second-level claim payment appeal. If a provider disagrees with the outcome of the claim payment dispute, providers may request a second-level review, also known as a claim payment appeal.

Both steps can be done via Availity Essentials, fax, or mail. They can also be submitted verbally through Provider Services.

For more information regarding the claim payment dispute process, refer to this document: Claims disputes and appeals, and clinical appeals for UM decisions

 

To check the status of a claims dispute or appeal:

  1. From the Availity Essentials home page, select Claims & Payments from the top navigation.
  2. Select Claim Status Inquiry from the drop-down menu.
  3. Submit an inquiry and review the Claims Status Detail page.
  4. To escalate, dispute, or appeal a claim, follow the steps in this document: Claims disputes and appeals, and clinical appeals for UM decisions

Clear Claims Connection

To use Clear Claims Connection:

  1. From the Availity Essentials home page, select Payer Spaces from the top navigation.
  2. Select the health plan.
  3. From the Payer Spaces home page, select the Applications tab.
  4. Select the Clear Claims Connection tile.

To learn more about the services Availity Essentials offers to our providers, visit our Learn about Availity page.

Related resources

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Provider tools & resources

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