Availity eligibility and benefits inquiry

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This is a message from the payer. If you hover over it, you'll see specific details. What if both provider sections are the same provider?

Currently, you'll need to enter the provider's NPI again. We'll work on a future enhancement, so you only need to enter it one time. Will we be able to authorize medications through Availity or is that only for procedures? Medical drugs such as infusions can be requested in Availity.

View all pharmacy drugs requiring approval and how to request approval. What is Premera's timeframe to complete a prior authorization? Authorization requests are submitted to Premera in real-time. We typically respond to requests within 5 days, but it may take up to 15 days if we need additional information. Do you have to have the provider on your account to follow up on prior authorization requests? You can manually enter provider information, so adding them to your account via the Add Providers process on the Manage My Organization page is optional.

However, adding them helps you choose them from the Select a Provider drop down which will auto-fill their information. Do you ever get an automatic approval or do they all pend for review? Yes, some requests are auto-approved. Some services can be auto-approved based on the provider's TIN or service s and diagnosis es being requested. In this case you won't be required to provide additional information.

For the Authorization Inquiry page, how long does it take for a prior authorization completed by phone or fax to be loaded? We don't take prior authorizations by phone. The speed of loading a faxed request completely depends on the volume of faxes received. Submitting online through Availity gives you a faster response. You can upload handwritten notes as a. PDF and attach it to your request. We can accept all types of files, including doc, docx, gif, htm, jpg, pdf, png, ppt, pptx, tif, txt, xls or xlsx.

Call Care Management at , option 3 AK: , option 3. On the code check feature if a code requires review, but doesn't need it in certain situations i. The tool will do auto authorizations based on a specific code and diagnosis being submitted.

As for stopping them, the prior authorization process flow won't stop the requester. Does the code check tool provide member-specific benefit information for prior authorizations? The stand-alone code check tool doesn't provide member-specific benefit information see screenshot below.

The prior authorization checks to see if a code requires prior authorization and does include member-specific benefit information about the member's referral requirements and out-of-network benefits. I work at a residential substance abuse facility.

We use ICD codes, not procedure codes. How does that work in Availity? This would be an inpatient prior authorization request and we would accept ICD diagnosis codes. What happens if you have more than three diagnosis codes? Currently, the Availity tool only accepts 3 diagnosis codes. If you have more than three, you can include the additional diagnosis codes in the Provider Notes section.

What if I don't have a procedure code to add to my request? For inpatient notification requests, you don't need to add a procedure code. There will not be one for Lower Level of Care admissions.

Can I submit a Premera PCP referral request to a specialist on Availity or is it only for prior authorization requests? At this time, it's for prior authorizations only. Providers can only submit prior authorizations through Availity for Premera plans. We're not using Availity for PCP referrals yet. Does this replace referral authorization submissions via Premera's current secure portal for Premera Medicare Advantage?

Premera Medicare Advantage continues to use Advantasure. Can I submit a referral through Availity for Amazon and Microsoft patients? No, we're not currently submitting referrals through Availity. Can this be used for retroactive prior authorization submissions? Prior authorization needs to happen before the service is performed; after that you would submit a claim.

What about Evolent and Advantasure secure tools? Providers will continue to use OneHealthPort's secure single sign-on process to access Evolent, Advantasure, Availity, and other health plan provider portals. If requesting services through Availity, you'll be directed to complete the request through AIM or eviCore. Do I submit prior authorizations through Availity for high-tech imaging? Can we submit through Availity instead, or do we still need to submit through eviCore?

If you submit your requests through eviCore today, you'll continue to submit through eviCore. Do prior authorizations for individual plans go through Availity now?

No, you will need to continue to go through Evolent secure portal for individual plans. Does everyone have access to AIM? It's not listed on my account. AIM is a third-party vendor for certain types of services. If a service is required to be completed by AIM, you'll be directed by the health plan payer to complete your request through AIM. The process flow for prior authorizations includes a check to see if a code requires prior authorization before completing a request. The requester can't move forward with completing the request through Availity.

Does this mean we no longer go through eviCore for any Premera Blue Cross members? Prior authorization service requests that go through eviCore today will continue to go through eviCore. Once a case is processed, can you view the denial letter on the portal, or at least the reason for denial criteria? No, not at this time. It will give you a denial and a denial reason and you'll get a separate letter with the denial details.

If a prior authorization request is denied, is the denial letter available in Availity? The denial letter is sent directly to the member and the requesting provider. Will Availity provide a denial reason? Yes, but Availity only provides a high-level denial reason. The denial letter provides complete details. Are the denial and approval letters faxed? Yes, the letters are faxed to the requesting provider. When a prior authorization is denied, is there an option to appeal through Availity such as a peer-to-peer review or a phone number to call?

Not at this time. Details about appeals are in the denial letters. Can we appeal through Availity? Premera requires a signed member authorization for all appeals submitted on the member's behalf. The member appeal form includes an authorization section for the member to sign and date.

Providers need to coordinate the submission of appeals with the member as the signed member appeal form must be included with any supporting documentation or medical records relevant to the appeal.

Appeals related to contracted rates or provider payments aren't member appeals and don't require member authorization. OHP remains as our gateway vendor for single sign-on activity. Instead of signing in repeatedly to multiple health plan portals, OHP users sign in just once and get secure authentication for many health plans. We'll continue to use OHP for single sign on authentication. Premera's secure provider tools will transition to Availity starting September Register and get training.

How do I get more Availity training? That will open the Availity Learning Center. You can also contact Training Availity. If I have technical issues with Availity, who do I call? What if we try to set up an Availity account and find that one already exists? Does it provide the administrator's name? For security purposes, no, it doesn't give the administrator's name.

For OneHealthPort account or log-in questions, call Will we receive an error message or be guided to contact the health plan? If you receive an error message while using the Availity tools, please reach out to Availity Client Services at , Monday through Friday, 8 a.

What's the difference between Availity and Availity Essentials? More information regarding authorization requirements can be found in the applicable provider manual:. You do not need to submit a request in this case. Watch the Availity Essentials Messaging a Payer training video or view the Messaging help topics for specifics on how to access and use this feature requires login to Availity Essentials. Once the appeal is received, you can verify appeal status as noted above.

Do not re-open a message after 30 days. If you have an additional question regarding the same claim, please submit a new direct message request.

Can you please provide more information regarding this denial? For detailed instructions, see Availity Essentials help topics for Transaction Enrollment requires login to Availity Essentials. Once enrolled the access to the administrator should be granted immediately.

The administrator can then grant access to other users within their facility accordingly. For detailed instructions, see Availity Essentials help topics for Remittance Viewer requires login to Availity Essentials. If a provider is signed up for Availity Essentials, the ERA tool can be utilized, even if the claim was not submitted through Availity Essentials.

For more information and instructions, see Directory Validation Instructions. Information regarding ERA can be found above. You can check your EFT submission progress status at any time by accessing the Transaction Enrollment page. Reimbursement for claims submitted after the EFT effective date will send payment electronically. Learn more information on how to register by reviewing the Availity Essentials getting started course.

To begin registration on Availity Essentials click here. Note: Access is granted shortly after registering. However, if the information submitted does not complete a match, it will be manually reviewed, which can take up to 60 days.

For technical issues or questions regarding how to use Availity Essentials contact Availity Essentials Client Services. Phone Number: Monday through Friday, 7 a. Once registered with Availity Essentials you can take advantage of on-demand, free training courses and resources to learn about administrator responsibilities, how to submit a claim, sign up for payment remittance advice notification and more! Log in to your Availity Essentials account to access training videos and resource materials through:.

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Stay updated on HealthCare News Get timely provider information including policy, benefits, coding or billing updates, education, and more—delivered directly to your email. Enter email Error: Please enter a valid email Subscribe. Availity Essentials. Available Functionality Availity Essentials Registration Availity Essentials Questions Training and Resources Available Functionality Below is a list of the main functionalities a provider may use within Availity Essentials, along with additional details that may apply to each category.

Submit eligibility and benefits inquiries for members To access Eligibility and Benefits: Log in to Availity Essentials Click Patient Registration Choose Eligibility and Benefits Inquiry in the drop down Select the appropriate payer and enter applicable details in the search fields Click Submit For detailed instructions, see Availity Essentials help topics for Eligibility and Benefits requires login to Availity Essentials.

Be sure to select the right payer when searching Eligibility and Benefits. For Out-of-state BlueCard plans, the amount of information can vary. Request authorizations Also known as precertification, preauthorization, or prior authorization. A listing of services requiring precertification can be found on our website.

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