Physical Therapy. Getting Started. Accessing Eligibility and Benefits Inquiry. Go to availity.com. Select Web Portal Users Login.

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1 Physical Therapy The Availity TM Eligibility and Benefit Inquiry allows providers to instantly confirm real-time patient eligibility and benefits, including covered services, copays, deductibles and more. Below you will find detailed instructions outlining how to obtain patient benefits on services rendered by your specialty. Verification of eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member s eligibility, any claims received during the interim period and the terms of the member s certificate of coverage applicable on the date services were rendered. 1. Getting Started Go to availity.com Select Web Portal Users Login. Enter User ID and Password. Select Log in button. Only registered users can access Eligibility and Benefits Inquiry. 2. Accessing Eligibility and Benefits Inquiry Select Eligibility and Benefits from left-hand menu. Select Eligibility and Benefits Inquiry. Contact your Primary Access Administrator (PAA) if Eligibility and Benefits is not listed in the navigation menu. August 2014 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. 1

2 3. Payer Selection Select BCBSIL from the Payer drop-down for local policies. Select Other Blue Plans for out-ofstate policies. BCBSIL The Organization field will autopopulate with the name of your practice/facility.* Contact the patient s home plan via BLUE for additional information pertaining to eligibility and benefit verifications for out-of-state members. * Users managing eligibility and benefit verifications for multiple Tax IDs should select the applicable practice/facility name from the Organization drop-down. 4. Provider Information Select the rendering physician s name from the Express Entry- Provider drop-down. This will autopopulate the rendering (Type 1) NPI in the NPI field.* Complete the following: Provider Type Place of Treatment In most instances, professional providers should utilize the treating physician s rendering NPI (Type 1) to receive an accurate benefit quote. If the rendering physician treats at multiple organizations., the City, State and Zip Code fields should be utilized. * If the applicable provider name does not appear in the Express Entry-Provider drop-down, enter the NPI into the NPI field. Then, place a checkmark in the Save this provider box. 5. Patient Information Select Physical Therapy from the Benefit/Service Type drop-down.* Next, complete the following: Patient ID (including alpha prefix) Date of Birth Physical Therapy Select Submit. The As of Date can be changed to submit inquiries for a past or future date of service. Past date inquiries can be received up to 12 months prior to the current date. Future date inquiries can be requested within the current month. * Reference page 7 for other applicable Benefit Service Types and their returns. A list of your most frequently used Benefit/Service Types will appear at the top of the drop down. 2

3 6. Eligibility Summary Results Eligibility for the requested patient will be displayed in the upper portion of the results screen. Results include, such as: Patient Information Subscriber Address Plan Date (current effective date) Group Number and Name Coverage Status Policy Type Pre-existing Information* Other or Additional Payer* Kanady, J ne 03/31/1984 AAA Female ANYWHERE AVENUE ANYWHERE, IL /0/ /31/ TEAM AWESOME Health Benefit Plan Coverage PPO MEDICAL Participating Provider Option (PPO) Pre-existing Condition Plan Waiting Period 09/23/2014 * The Pre-existing Status and Other or Additional Payer fields will only appear if this information is applicable. MEDICARE Medicare Part A 01/01/ /31/9999 Grace Periods Some individuals who purchase insurance through the health insurance marketplace may receive an advance premium tax credit (APTC). These members qualify for a three-month grace period to pay their premium provided they have already paid at least one month s premium in full. All allowable services provided during the first month of the grace period will be the responsibility of BCBSIL, subject to member cost sharing. BCBSIL will pend all claims incurred during the second and third months of the grace period. If the member pays all outstanding premium payment(s) in full, the claims will process according to the member s benefits. The Plan /Product Information section of the Eligibility Results screen will provide a grace period indicator for applicable members, including grace period start and end dates, as shown in the example below. Not all members who purchase coverage on the health insurance marketplace will receive the APTC. 3

4 7. Benefit Summary Results The network status and associated benefit descriptions will be listed at the lower portion of the Eligibility and Benefits Summary Results screen. Results include: Coverage Level (individual or family) Amount (patient responsibility) Quantity (limitations or maximums) Place of Service Time Period (Visit, Calendar year, Lifetime, etc.) Description (applicable services) Responses for Physical Therapy include Physical/Mechano-Therapy. Only applicable benefits will be displayed. The below example does not show a copayment; therefore, no copayment applies to these services. Select View Additional Benefits to access universal deductible information and additional benefits that may relate to the Benefit/Service Type used to start the inquiry. The benefits returned in the View Additional Benefits box will differ depending on the Benefit/Service Type selected on the Eligibility and Benefits Inquiry screen. If no additional benefits are listed, then none are available outside of what is returned in the benefit table. 4

5 8. Universal Deductibles and/or Out-of-Pockets A Universal Deductible or Out-of- Pocket is one deductible or out-ofpocket applied to multiple benefits within a policy. From the View Additional Benefits listing, select the In Network or Out of Network link located to the right of Health Benefit Plan Coverage. * * Users should select In Network or Out of Network based on the network status reflected above the benefit table (reference step 7). The benefit table will display the patient s applicable deductible information, including original and remaining amounts. If the benefit table does not return on the Health Benefit Plan Coverage screen, no deductible or out-of pocket applies. 9. View Details Select View Additional Benefits. Select the In Network or Out of Network link for Physical Therapy. The system will navigate back to the original benefit screen. * * Users should select In Network or Out of Network based on the network status reflected above the benefit table (reference step 7). Select View Details to view applicable benefit qualifiers or preauthorization requirements. The View Details button is located at the top and bottom of the Eligibility and Benefit Summary Results page. This feature should be utilized for every transaction. 5

6 10. Benefit Qualifiers and Preauthorization Indicators Below are examples of benefit qualifiers that may be returned depending on the patient s benefit contract. This information will be located on the View Details page. If these field do no return, then no benefit qualifiers or preauthorization requirements apply. IL 11. Speak to an Agent Feature In some instances, benefit information may not be readily available online. We are proud to offer an innovative feature for a quick transition from web to phone. The Speak to an Agent feature gives priority access to the next available customer advocate during standard business hours. Select the Speak to an Agent button. Dial the 800 number provided in the pop-up box. Enter the 8-digit reference ID number via your touch tone key pad. This feature will only be available for medical benefits that are managed by BCBSIL. The Speak to an Agent button will not be offered for benefit information managed by other entities (i.e., vendors, government programs and labor fund carve outs). 6

7 12. Additional Benefit Options The left column below lists the most frequently used Benefit/Service Types utilized by physical therapy providers. The right column illustrates the Availity responses. To access these benefits, select the View Additional Benefits link on the Eligibility and Benefit Summary Results page. The link will be located above the benefit table. Benefit / Service Type Selection Benefit Return Diagnostic X-ray Physical Therapy Physician Visit-Office: Sick Prosthetic Device X-ray Physical/Mechano-Therapy Office visit Injections Laboratory X-ray* Surgery* Orthotics * To access these benefits, please click the View Additional Benefits link on the benefit return. Questions? the Provider Education Consultants at pecs@bcbsil.com. Be sure to include your name, direct contact information, Tax ID or Billing NPI. Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors such as Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly. 7