Availity ' Eligibility and Benefits SM'

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1 Updated 12/2012 Availity ' Eligibility and Benefits SM' An eligibility and benefits inquiry should be completed for every patient at every visit to confirm membership, verify coverage and determine other important information, such as the patient s copay, coinsurance and deductible amounts. Eligibility and benefits inquiries may be completed online easily and efficiently using the Availity Eligibility and Benefits tool. Note: Unless otherwise required by state law, this notice is not a guarantee of payment. Benefits are subject to all contract limits and the member s status on the date of service. Accumulated amounts such as deductible may change as additional claims are processed. Getting Started Primary Access Administrators (PAA): Before your users can begin, you will need to grant them access by going to Account Administration Assign Access to Users Manually Assigned Eligibility and Benefits Users: Please confirm with your PAA access has been granted. Signing on to Availity 1. Go to the Availity website at availity.com 2. Key in your user ID and password. 3. Click Login.* *To access the Eligibility and Benefits tool, you must be a Registered Availity user. You may register online at availity.com, or call Availity Client Services at 800-AVAILITY ( ) for assistance. Accessing the Tool Once you log into Availity, click Eligibility and Benefits, then select Eligibility and Benefits Inquiry 1

2 Eligibility and Benefits Entry Next, you need to complete the Eligility and Benefits Inquiry screen. Entry Fields: (**Required Fields) Payer - select BCBSTX for local inquiries or Other Blue Plans for out-of-state inquiries Provider Information o Organization** o Express Entry Provider - Select provider's name to automatically populate other provider-related fields o Provider Type**- Professional=1500 claim or Facility / Institutional=UB04 claim o NPI** o City o State o ZIP Code o Place of Treatment** Patient Information o As of Date - Defaults to today s date. o Type of Benefits Requested** o Search Option Patient ID & DOB will be default. When using CareRead use the Patient ID, Name & DOB Search Option. o Patient ID**- with alpha prefix o Patient Date of Birth**- MM/DD/YYYY o Patient s Relationship to Subscriber o Patient Gender After completing all of the required fields, click Submit. 2

3 Eligibility and Benefits Summary Results Eligibility Information Eligibility and policy information is displayed in the upper portion of the screen. 3

4 When the search information is entered and the information retrieved differ, the below message will be returned on the Eligibility and Benefits Summary Results page. NOTE: The member information displayed above this message is the most up to date information on file. Effective Date Effective date is found under the Plan. Pre-Existing Information The Completion field references a date upon which the Pre-existing waiting period concludes. 4

5 Other or Additional Payer If the patient being displayed has other carrier information on record, it will be reflected in the Other or Additional Payer section. This section will not display if our records do not indicate other insurance. NOTE: The information displayed will include: Payer order (Primary or Secondary), the other carrier name, and the name of the insured on the other carrier s policy. The benefit order returned will be specific to the patient being searched. Benefits Information Detailed benefit information populates at the bottom of the Eligibility and Benefit results page. 1. Eligibility & Benefit Information indicates the information being returned on each line such as Copayment, Coinsurance, Deductible, etc. 2. Coverage Level displays if the coverage is at the individual or family level. 3. Amount represents the member s portion of responsibility. 4. Quantity specifies number of applicable services (i.e. visits, days, etc.). 5. Place of Service 6. Time Period designates applicable times for each line such as Calendar year, Service Year, per Visit, etc. Service Year was formally known as Contract Year. 7. Description of the service for which benefits are being returned. 8. View Additional Benefits allows additional related benefit options. NOTE: All applicable maximums are displayed. If there is no maximum is displayed, no maximum will apply. 5

6 View Additional Benefits When View Additional Benefits is selected, the related benefit returned will differ depending on the initial benefit searched. The below example references the related benefits returned when Surgical was the original benefit searched. Universal Deductible and Out-of-Pocket A Universal Deductible or Out-of-Pocket is when one deductible or out-of-pocket applies to multiple benefits within a policy. To ensure a complete and accurate benefit quote is obtained, follow these steps: Select the most appropriate Benefit/Service Type for the services being rendered If View Additional Benefits is available and Health Benefit Plan Coverage is listed, select Health Benefit Plan Coverage o The description will indicate if the deductible and/or out-of-pocket applies to the services being rendered When View Additional Benefits is not returned, or Health Benefit Plan Coverage is not displayed, no additional deductible or out-of-pocket would apply outside of what is returned within the original benefit category Please note, when the selected services return with a $0.00 deductible and/or out-of-pocket, this simply means these are not applicable to the chosen service; however, the policy may have a deductible and/or out-of-pocket related to other services. View Details View Details should be used on every transaction to provide important information on the benefits requested. This option is available at the top and bottom of the Eligibility and Benefits Summary Results page. Benefit qualifiers on policies can only be viewed from the Detailed Results page through this option. Below are examples of existing policy benefit qualifiers that may be returned, depending on the benefit contract. 6

7 New Features Past Benefit Request Enter the past date in the As of Date field on the Eligibility and Benefit Inquiry page. A past date inquiry can only be received up to 12 months prior to the current date of the request. Future Benefit Request Enter the future date in the As of Date field on the Eligibility and Benefit Inquiry page. A future date inquiry can only be received for a date within the current month of the request. Remaining accumulated amounts will only be displayed for the current date. Benefit Return Changes Service Year, formally known as Contract Year, see page 5, field 6 Out-of-pocket and deductible display changes, see Universal Deductible and Out-of-Pocket section, page 6 7

8 Type of Benefit Requested There have been some changes in the Type of Benefit Requested options available. The table below contains Type of Benefits Requested which are now supported under a different request. Instead of searching: Professional (Physician) Visit Office Obstetrical / Gynecological Durable Medical Equipment Mental Health Diagnostic Medical Emergency Services Hospital Outpatient (Professional) Well Baby Hospital Surgical Benefits Professional (Physician) Search: Physician Visit Office: Sick Physician Visit Office: Well Obstetrical Durable Medical Equipment Purchase Durable Medical Equipment Rental Mental Health Provider Inpatient Mental Health Provider Outpatient Mental Health Facility Inpatient Mental Health Facility Outpatient Diagnostic X-ray Hospital Emergency Accident Hospital Emergency Medical Urgent Care Professional (Physician) Visit - Outpatient Pediatric Hospital Inpatient Hospital Outpatient Hospital Emergency Accident Hospital Emergency Medical Surgical For assistance, to gain access to the Eligibility and Benefit tool or find out about more free services available on Availity, call Availity Client Services at , or visit the Availity website (availity.com). Availity is a registered trademark of Availity, L.L.C., an independent third-party vendor. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by Availity. The vendor is solely responsible for the products or services offered by them. If you have any questions regarding the services offered here, you should contact the vendor directly. 8