Availity Essentials

Availity Essentials offers secure online access to multiple payers and the ability to check eligibility and benefits, manage claims, see remittances, request authorizations and referrals and complete other secure administrative tasks online.

Availity Essentials Portal is a multi-payer site where you can use a single user ID and password to work with BCBSND and other participating payers online. Availity Essentials is compliant with all HIPPA regulations and there is no cost for providers to register or use any of the online tools.

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. If you do not have access to any of these functions, please contact your Availity Essentials assigned administrator or administrator’s assistant.

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).

This function can be used for all BCBSND lines of business.

Be sure to select the right payer when searching Eligibility and Benefits. BCBSND has two different payer names/ID’s:

- 55891-BCBSND

Used for Commercial and Medicaid Expansion lines of business

- 55892-NextBlue of North Dakota Medicare Advantage plan

For Out-of-state BlueCard plans, the amount of information can vary.

If you return no results through the Eligibility and Benefits inquiry or need additional information, call the number on the back of the member’s insurance card or call the BlueCard Eligibility® line at 800-676-BLUE (2573) and provide the prefix.

International Blue Plans

Verify eligibility and benefits using one of two methods:

- Send an electronic inquiry through Availity Essentials; or

- Call the BlueCard Eligibility® line at 800-676-BLUE (2573) and provide the prefix

Choose the Benefit / Service Type field of Health Benefit Plan Coverage details. To search a specific benefit or therapy benefits, select the service type(s) that most align with the services you plan to provide. When narrowing your search to a specific benefit, only that detail will apply.

There are multiple options to search for members in the Eligibility and Benefits search function. The drop down under the Patient Search Option field will show these choices.

Member’s first and last name, date of birth, and patient ID will produce the most accurate result.

- If a member has multiple patient ID’s, you may yield no result found if only utilizing the member's first name, last name, and date of birth option. If this happens, utilize another search option field to enter more data, such as the Patient ID.

- Patient ID is the member's BCBSND unique member ID (UMI) from their BCBSND insurance card.

Additional Health Benefit Plan Coverage details can be found by scrolling within the Eligibility and Benefits populated search results. This screen will allow you to see All Networks, In Network or Out of Network, as applicable. Clicking these will show you coverage information, such as:

Coverage level, such as individual, family, etc.-This will help determine cost shares that may be noted on the members ID card.
Plan/Product type-i.e., Medicaid Expansion, YourBlue, etc.
Accumulation information, found under the Plan Maximums and Deductibles section as applicable.
Visit limitation information, found under the Benefit Information section.

Examples of what this information looks like is provided in the below screenshots. Please note, this information may vary.

Visit imitation example:

Submit claim transactions (837I & P), check claim status (276), etc. 24 hours a day, seven days a week.

To access Claim Status:

Log in to Availity Essentials
Click Claims & Payments
Choose Claim Status in the drop down
Select the appropriate payer
Enter the applicable details
Click Submit

For more information and detailed instructions relating to claims and/or claim status, see Availity Essentials help topics (requires login to Availity Essentials).

For more information regarding claim guidelines, refer to the appropriate Provider Manual:

Provider Manual

Medicaid Expansion Provider Manual

To enter a referral:

Log in to Availity Essentials
Click Patient Registration
Choose Authorization & Referrals in the drop down
Click the appropriate option for the product type
Select Referral Request

- Note: Referral requests are used for our BCBSND commercial line of business only

Enter the applicable details
Click Submit

To check the status of a referral

Log in to Availity Essentials
Click Patient Registration
Choose Authorization & Referrals in the drop down
Select Auth/Referral Inquiry or Auth/referral Dashboard

For detailed instructions, see Availity Essentials help topics for Authorizations and Referrals (requires login to Availity Essentials).

Note: How to submit a referral varies between BCBSND commercial products and the Medicaid Expansion lines of business. Additional information regarding referrals can be found within the appropriate provider manual.

Also known as precertification, preauthorization, or prior authorization.

Availity Essentials does not have the functionality to determine if a code requires prior authorization or not.

A listing of services requiring prior authorization can be found by utilizing the search tool on our website.

To access:

Find the BCBSND Provider webpage toolbar
Click Policies & Prior Authorization
Select Prior Authorization
Determine if the member is in network or out-of-area (network)
Search for the CPT/HCPCS code (in-network) or enter the three-alpha prefix (out-out-area)

Note: The search results listed do not apply to the Federal Employee Program (FEP), Medicare Supplements or NextBlue of North Dakota Medicare Advantage plans. Please contact the appropriate Provider Services for more details on those plan types.

Additional tips to assist with the review of an authorization request:

Availity UM Prior Authorization Tips

To enter an authorization request:

Log in to Availity Essentials
Click Patient Registration
Choose Authorization & Referrals in the drop down
Select Authorization Request
Enter applicable details
Click Submit

To check the status of an authorization:

Log in to Availity Essentials
Click Patient Registration
Choose Authorization & Referrals in the drop down
Select Auth/Referral Inquiry or Auth/referral Dashboard

NextBlue of North Dakota does not follow the same authorization submission process as noted above. To submit a NextBlue authorization, go to BCBSND Payer Spaces located within Availity Essentials, click the Resources tab and select the NextBlue Prior Authorization. Once selecting the Prior Authorization link, you will be redirected to the Symphony portal to enter the applicable information.

For detailed instructions, see Availity Essentials help topics for Authorizations and Referrals (requires login to Availity Essentials).

More information regarding authorization requirements can be found in the applicable provider manual:

Provider Manual

Medicaid Expansion Provider Manual

Please note, Medicaid Expansion has additional requirements for Emergency and Inpatient admissions.

Requests that do not require prior authorization and have a published BCBSND medical policy will be cancelled. 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).

Ask a question or submit a request to:

Check claim status or claim denial
Check appeal status
Check medical record submission status

- When a direct message is sent to verify if medical records were received, include details such as when they were sent and how many pages.

Requests not allowed through direct messaging include, but are not limited to:

Appeals

- Submit the appeal using our Appeal request form via fax or U.S. Mail. Once the appeal is received, you can verify appeal status as noted above.

Benefits
EOB attachments to adjust a claim.

- Providers will need to follow the process of sending a claim correction.

Medical records attached to a message without the BCBSND medical record request letter, or the Medical Record Submission form will not be accepted.

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.

Be specific in your question to avoid delays.

If the message or question does not have enough detail, you may receive it back asking for additional clarification.
Ensure you are looking at your remittances prior to sending messages for claim status/denial information.
If your question is regarding one line of a multi-line claim, be specific as to which line you are questioning.

- Ex: Instead of sending a direct message asking, “Why did this claim deny?” Include additional details such as the line and reject in question. “I reviewed the remit on this claim and do not understand why line two of the claim rejected as not medically necessary. Can you please provide more information regarding this denial?”

Receive claim acknowledgment (277CA) and claim payment/remittance advice (835) transactions through the Remittance Viewer option under the Claims & Payment section of Availity Essentials.

To sign up for ERA-Remittance Viewer:

Log in to Availity Essentials
Click on the Claims & Payments dropdown
Select Transaction Enrollment

- Note: The system will prompt you to authenticate.

Click Enroll
Follow through the prompts to submit your request.

For detailed instructions, see Availity Essentials help topics for Transaction Enrollment (requires login to Availity Essentials).

This can only be completed by the Availity Essentials assigned administrator or administrator assistant.

- If you do not have access, please contact your administrator.

Once enrolled the access to the administrator should be granted immediately. The administrator can then grant access to other users within their facility accordingly.

To view a remittance advice:

Log in to Availity Essentials
Click on Claims & Payment
Select Remittance Viewer
Search and view your remittances accordingly

For detailed instructions, see Availity Essentials help topics for Remittance Viewer (requires login to Availity Essentials).

You must be enrolled with the payer ID 55891 and/or 55892 to view remittances for that line of business.

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.

To access BCBSND credentialing forms and tools from Availity Essentials:

Once logged in, click on Payer Spaces
Click the BCBSND icon

- To search for credentialing forms, select forms on the left-hand side, then choose the appropriate form.

- You can access the Provider Directory Validation maintenance tool here as well. For more information and instructions, see Directory Validation Instructions.

In order to sign up for EFT, you must have successfully enrolled for ERA. Information regarding ERA can be found above.

To sign up for EFT:

Log in to Availity Essentials
Click on the Claims & Payments dropdown
Select Transaction Enrollment.
Click Enroll
Follow through the prompts to submit your request.

- When inputting the NPI number, ensure you are using the group NPI, not an individual practitioner's NPI.

For detailed instructions, see Availity Essentials help topics for Transaction Enrollment (requires login to Availity Essentials).

This can only be completed by the Availity Essentials assigned administrator or administrator assistant.

- If you do not have access, please contact your administrator.

You can check your EFT submission progress status at any time by accessing the Transaction Enrollment page.

If approved, it will show an accepted status and effective date.
If denied, it will show a rejected status and a reason for the rejection. You do have the ability to resubmit if the status shows rejected.

EFT can take up to 60 days to be reviewed and completed.

Once approved, you will see the approved EFT status, with a note confirming the EFT effective date. Until that effective date begins, you will receive paper checks in the mail.

- Any reimbursement for claims submitted prior to the EFT effective date will arrive as paper checks. Reimbursement for claims submitted after the EFT effective date will send payment electronically.

- EFT information submitted within Availity Essentials will apply for all lines of business a provider is participating with (commercial, Medicaid Expansion and/or NextBlue). Providers will be unable to associate different bank accounts for different network affiliations.

Availity Essentials Registration

Learn more information on how to register by reviewing the Availity Essentials getting started course. Once you are on the Availity Essentials website, read the descriptions outlined on the registration page for each type of account. After identifying the type of user account you need, explore the training site for more details on the registration process, or start creating your account.

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.

Availity Essentials Questions

For technical issues or questions regarding how to use Availity Essentials contact Availity Essentials Client Services.

Phone Number: 1-800-282-4548
Monday through Friday, 7 a.m. to 7 p.m. CST

Technical Support Direct message available 24/7 on www.availity.com.

Training and Resources

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!

Help & Training

“Find Help” will allow you to search for information within their Provider Help Center.
You can also select “Get Trained” for access to Availity Essentials training courses.

- There is a wide variety of categories and videos to select to narrow your search as needed.

Keyword Search

This functionality allows you to search by keywords such as EFT or Administrator.

Payer Spaces

Payer Spaces will provide information on BCBSND resources, forms relating to BCBNSD, including the Provider Directory Validation Maintenance tool, news, and announcements.

Additional Tips

To find your Availity Essentials assigned administrator, see Availity Essentials help topic My administrators (requires login to Availity Essentials).

BCBSND utilizes Change Health Care® Level of Care Criteria (InterQual) which is based on nationally recognized clinical guidelines to assist clinicians in making informed decisions. InterQual criteria sets are via the InterQual (BCBSND) link on Availity Essentials under the Authorizations & Referrals section.

More information regarding Availity Essentials may be found in the HealthCare News section.

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Medical Policies Quick Search

Availity Essentials

Submit eligibility and benefits inquiries for members

Submit new claims, make claim corrections or voids, and review claim status

Request referrals

Request authorizations

Direct Messaging

View your electronic remittance advice (ERA)

Complete credentialing forms

Complete and/or update electronic funds transfers (EFT) information