NaviNet Open

NaviNet Open Foundation consists of a series of layers: a platform, a set of network services, a suite of reimbursement-related and clinical applications, and a set of tools that customers can use to configure and customize the system. NaviNet’s creation of a “smart” next-generation payer-provider healthcare communications network that connects Big Data informatics systems developed by health plans, delivery systems, and software vendors to the heterogeneous provider community enables the sharing of critical real-time intelligence and rapid innovation in response to the quickly changing demands of healthcare reform.

The NaviNet Open Foundation supports all NaviNet Open Solution offerings. It features event-based architecture that, along with complex event processing, allows NaviNet to “listen” for discrete and relevant events across the network and respond in real time with critical information needed by provider users. Static and interactive reports, along with alerts and notifications, are part of the Foundation. NaviNet Open APIs allow integration with third-party systems and applications— this is the hallmark that makes us Open. Health plans may also use the platform for developing their own applications, either using their in-house IT resources or working with NaviNet’s Professional Services organization. Third party developers will also be able to license access to the platform and the NaviNet network for producing applications of interest to providers and consumers.

NaviNet Open Multipayer Portal Applications

NaviNet Open, our flagship next-generation payer-provider communications solution, integrates reimbursement-related and clinical workflows. NaviNet Open supports basic HIPAA transactions such as Eligibility and Benefits, Claims Management, Referrals and Authorizations and more. Unlike conventional payer-provider portals built as extensions to clearinghouse technology, NaviNet Open offers a set of customer-configurable applications that provide rich detail for enhanced transactions. The accurate and complete information for non-standard transactions boosts provider engagement and adoption, enabling true payer-provider collaboration to be achieved.

Eligibility and Benefits

The NaviNet Open Eligibility and Benefits (E&B) application delivers rich detail directly to the user in an easy to use and consumable fashion for insurance eligibility checks. Information including co-payments, deductibles, and many specialties is not only accurate and complete but also includes the depth and breadth of information required by providers. Instant access to this information increases administrative efficiency through decreased phone calls and increased savings with patient data that is more accurately complete. With increased administrative efficiency, the provider staff is more available for patient care and clinical work, necessary to impact patient positive outcomes.

Claims Status Inquiry

The NaviNet Open Claim Status Inquiry (CSI) is a powerful provider solution that delivers rich claim information content in real-time.  The Claims Status Inquiry allows providers and their staff access to real-time, detailed claim status information for a patient eliminating the need for providers to call a health plan directly. Users can check claim status at any time following a claim submission and can check for all claims regardless of submission method. The NaviNet Claim Status Inquiry application provides the health plan with a set of powerful configuration options for both the CSI user interface and the CSI API.  NaviNet Open's Claim Status Inquiry transaction is the result of many years of experience and successful implementations.



NaviNet Open Referrals enable providers to submit a referral, modify an existing referral and request the status of a submitted referral. The referred to provider list can be managed by health plans, enabling them to decide whether Out of Network referrals are allowed. Rapid implementation through the use of standard EDI communications and configuration tools helps lower both initial and ongoing costs. The combination of a standard, productized referral application with the ability to configure will provide IT with both flexibility and built-in best practices.


NaviNet Open's authorization application provides customers with configurability and adaptability that will enable business owners to respond nimbly to changes in networks and benefits that affect authorization requirements. Intelligence built into the authorization request process, before submission to the healthplan Utilization Management team, creates an opportunity for efficiency and quality in the request. That intelligence, combined with EDI standards-based transmission, will allow automation of many determinations. Where human review is required, intelligence in authorization preparation accelerates the assembly of supporting information, including management of clinical attachments.

Claims Management

NaviNet Open Claim Management is a suite of powerful, yet easy-to-use claims-related provider applications consisting of web-based Claim Entry and Submission, Claim Repair, Claim Adjustment, Claims Log, and Claim Attachments. With these applications, provider office users can submit new claims with or without attachments, repair and re-submit rejected claims, and adjust claims that were processed or paid incorrectly due to a billing error. Notably, Claim Adjustment and Claim Attachments are both able to support any claim – regardless of whether the original claim was submitted through NaviNet, a practice management system, or even a clearinghouse. With NaviNet Open Claims Management, health plans finally have a solution to eliminate costly paper claims and attachments as well as the phone calls and manual processes associated with claims follow-up, correction, and resubmission. Additionally, providers now have access to a powerful set of claim-related applications without needing a sophisticated EMR or even a practice management system.

Provider Data Management

The NaviNet Open Provider Data Management (PDM) Application is a web-based, multi-payer application that allows providers to update, validate, and attest to their provider information directly. The Application allows providers to communicate provider information updates to health plans in support of the Centers for Medicare and Medicaid Services (CMS) and state-based network adequacy mandates.  The NaviNet Open Provider Data Management Application enables health plans to improve provider directory accuracy, increase operational efficiency, and adhere to compliance and audit checks.