Eligibility, Benefits and...

Eligibility, Benefits and Pre-certifications

Availity Customer Connection 2011

©2011 Availity, LLC | All Rights Reserved 1

What We Will Cover Streamline administrative workflow with a single, no cost, online connection to multiple health plans.

• CareRead ® • Eligibility and Benefits Inquiry • Authorizations and Referrals


CareRead® CareRead lets you swipe a patient’s health plan member ID card, containing a magnetic stripe, through a card reader device.

• Automatically populates Availity's transaction pages with demographic and insurance information, reducing time-intensive manual data entry.

• Works seamlessly with our Eligibility and Benefits Inquiry and CareProfile® services for end-to-end patient processing.

• Reduces data entry errors and corrections. • Streamlines up-front tasks to improve patient flow through the

medical practice. • Complies with regulatory requirements and is fully secure.


CareRead® Ordering card readers

• Order from a business retailer or online (search for “magnetic card reader“). Visit Availity Help for more information.

Installing card readers • Insert the card reader connector into the USB port on your

computer. Using card readers

• Swipe the patient’s insurance ID card with the magnetic stripe facing the light on the card reader.

• Many of the fields on the applicable forms are automatically populated with the patient’s information.





Eligibility and Benefits Inquiry Instantly confirm patient eligibility and benefits (E&B), including covered services, co-payments, deductibles, and more at no charge. No more phone calls or paperwork.

• Save money with this no cost service. • Save time retrieving eligibility and benefits information from all

of your health plans in one place. • Improve accounts receivable with up front information. • Save time by working online, in real-time, using convenient

search criteria. • Leverage existing software with Availity’s seamless integration. • Fully secure and compliant with HIPAA regulatory requirements.


Eligibility and Benefits Inquiry 1. Click Eligibility and Benefits | Eligibility and Benefits

Inquiry. 2. Select the payer and let the page refresh.

• For additional payer guidelines, click the ? next to the Payer field for more information. For example, select the OTHER BLUE PLANS – BCBSGA option for all transactions destined to an out-of-state Blue payer. Blue Cross Blue Shield of Georgia routes the transaction as appropriate.

3. Complete the required fields and click Submit. 4. View and print the results.

a. Click Print. b. Click Edit Inquiry. c. Click View More. d. Click View Details. e. Click additional payer link-outs for additional benefit

notes, remaining deductible, or calendar/plan year information.


Eligibility and Benefits Inquiry Example


4010 example

Eligibility and Benefits Inquiry Example


Availity displays the correct version when you select the payer.

Partial 5010 example

For Humana, click View ID Card to access the Humana portal and view the member’s letter of coverage or ID card.

Humana - Medical Proof of Coverage


If the patient does not have an ID card, enter the subscriber’s information.

Eligibility and Benefits Results Example



Eligibility & Benefits (E&B) Summary Results



5010 E&B Results – Other or Additional Payer

Other or Additional Payer section


5010 E&B Results – View Additional Benefits

View Additional Benefits link


5010 E&B Results – Service Type • Service Type table • Value adds


5010 E&B Detail Results – Service Type Expanded Service Type sections:

• Co-Payment • Co-Insurance


5010 E&B Detail Results – Service Type, cont.

Expanded Service Type sections:

• Deductible • Limitations


5010vE&B Detail Results – Service Type, cont.


Expanded Service Type sections: • Out of Pocket

(Stop Loss) • Contact Following

Entity for Eligibility or Benefit Information

• Payer Contact Information

Clinical Messages Eligibility & Benefits

19

• All sensitive clinical messages are excluded from E&B delivery. As a result, if the member has a medication graph associated to chronic medications, a message header displays to let you know that the medication graph is available via CareProfile. In order to view the actual medication graph, the user must request CareProfile.

• The number of clinical messages delivered via E&B is limited to three messages.

• All available clinical messages, including sensitive clinical messages will be returned.

Payer Name Goes Here

Clinical Messages ─ Icons

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Significant Alert • Signifies important messages about a

members health. For example, Diabetes needs annual urine protein screen.

Educational Tip • Denotes a message that may improve a

member’s health. For example, Diabetes needs annual urine protein screen.

Medication Graph • Chronic Medications: 6 month history

available via CareProfile

Eligibility & Benefits Summary Overview


Type indicates messaging icon.

The date is the Analysis As Of Date (AAOD),

which is the date when a clinical

activity was expected to take

place.

Print Page prints the eligibility responses and

the message detail.

Print Message Detail will print the detail of the messages within the

Provider Feedback form.

Data Source is the name of the health

plan that sent out the message.

CareProfile enables you to request the

CareProfile, which give all messages and the claims history for that

member. Edit Inquiry enables users to edit the information they supplied during the

initial query.

Payer Name Goes Here

Printing Clinical Messages

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1. After clicking Print Message Detail, the user is prompted to select a provider and click the Print and Close Window button.

2. If the provider name is not listed, the user should choose Provider Not Listed from the drop the drop-down list. The list of providers that displays in the drop-down window have been added by your organization’s PAA into the Maintain Provider database. By entering the provider names in the Maintain Provider database, users can take advantage of Express Entry.

3. Click Print and Close Window.

Steps continued on next slide

Patient Highlights Provider Known Form

23

• The provider feedback Patient

Highlights form (PDF) document displays. In this example, since the Physician Name and ID are known, the provider is asked to:

1) Print the Patient Highlights

document. 2) Place a checkmark beside each

option, as it applies to the patient. 3) Add any additional comments 4) Fax the Patient Highlights

document to 1-888-703-7076.

Payer Name Here

Patient Highlights Provider Unknown Form

24

• Since the Physician Name and Physician ID are unknown, the user is asked to include these details, add any additional comments, and fax the Patient Highlights report to 1-888-703-7076.

Payer Name Here

No Cost Real-Time Medicare E&B Registration

1. Log in to the Availity portal. 2. Click My Account | Medicare E&B Registration.





Authorizations and Referrals Availity’s Authorizations and Referrals feature lets you submit authorization and referral requests in real time. With the Authorization and Referral Inquiry feature, you can easily check the status of existing authorizations and referrals.

• Any Availity user who represents the requesting, referring or referred-by provider, or the referred-to provider or facility can inquire about an authorization or referral.

• In general, you can inquire about all authorizations and referrals, including those not submitted originally in Availity. Contact the payer to determine any exceptions to this rule.


Referrals Use the Referrals feature to submit a referral request.

1. Click Auths and Referrals | Referrals. 2. Select the payer and let the page refresh. 3. Additional required fields display based on payer requirements. 4. Complete the required fields and click Submit.

Looking for a detailed referral form? • The Referral page is a quick referral form. For a detailed version

for payers still participating in 4010, click Auths and Referrals | Authorizations. In the Transaction Type field, click Detailed Auth/Referral.

Need help deciding which form to use? • Use Availity Help or field-level help to learn more about payer

requirements. Did you receive a pended status?

• Use Availity’s Auth/Referral Inquiry to check the status later.


Referrals



Referrals



Humana 5010 Referral


• Find a Provider button: Click Find a Provider to search for providers to which you are referring a patient.

• Find A Facility button: Click Find a Facility to search for facilities to which you are referring a patient.

Partial example

Authorizations Use the Authorizations feature to request an authorization.

1. Click Auths and Referrals | Authorizations. 2. Select the payer and let the page refresh. 3. Select the transaction type. 4. Additional required fields display based on payer requirements. 5. Complete the required fields and click Submit.

Need help deciding which form to use? • Use Availity Help or field-level help to learn more about payer

requirements. Did you receive a pended status?

• Use Availity’s Auth/Referral Inquiry to check the status later.


Authorizations



Authorizations



Auth/Referral Request - Result



Authorization and Referral Inquiry View the results of an existing authorization or referral or inquire about the status of a request using this feature.

1. Click Auths and Referrals | Auth/Referral Inquiry. 2. Select the payer and let the page refresh. 3. Complete the required fields and click Submit. 4. View and print the results.


Auth/Referral Inquiry



Auth/Referral Inquiry



Authorization and Referral Inquiry Result • Responses vary by payer, 4010 or 5010 version and type of

authorization or referral. • Multiple responses may occur if they match all of the criteria

you specified in the inquiry. • If the payer approves the request, the Certification # field

displays under Certification Information. • If the payer rejects the request, a Rejection Reason field

displays instead. • Some payer responses display a View More button. Click this

button it to expand the section and review the fields as needed.


Auth/Referral Inquiry Result



Auth/Referral Inquiry Result



Auth/Referral – Upload Attachments For Humana Providers If you determine you need to include attachments to a pended referral or authorization request, follow these steps:

1. On the authorization or referral results or inquiry page, click the Upload Attachment link. A new browser window opens and displays a third party disclaimer.

2. Click I Agree to accept the disclaimer and access the Humana attachment application.

3. Follow the instructions on the Humana website to upload your attachments.

Note: You must be assigned the Authorization and Referral Request role to use this feature.


Authorization and Referral Link-Outs • Availity offers links to many health plan-specific tools through

single sign-on capability. • Some tools require additional steps or registration with the

health plan for access. • To learn more about these payer links, click Help at the top of

any page and click the payer’s name under Contents.


Thank you

Call 1-800 AVAILITY (282.4548)

Or visit us online at availity.com


http://www.availity.com/�

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