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 you will find general information pertaining to BCBSND that is applicable to the Availity Essentials provider portal.

To find more detail on how to utilize each functionality, log in to Availity Essentials, click on Payer Spaces-BCBSND. Under the Resources tab, select the link to Availity Functionality for BCBSND.

This is used to verify plan benefits and member eligibility.

Not all plan benefits will display within Availity. Contact the Provider Service Department phone number on the back of the member ID card for additional benefit information.

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 the applicable options.

For more information on how to use Eligibility and Benefits, the types of patient search options, view limitations and other coverage information, see the BCBSND Payer Spaces guide (requires login to Availity Essentials) noted above.

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

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

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

Provider Manual

Medicaid Expansion Provider Manual

Visit https://www.nextbluend.com/provider-resources to access the NextBlue Provider Manual

To enter a referral or check the status of a referral see the detailed instructions available in the Availity Essentials help topic section for Authorizations and Referrals and/or utilize the BCBSND Payer Spaces guide (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.

A listing of services requiring precertification can be found on our website or within the Availity Essentials portal. The precertification check within Availity Essentials will happen in the Authorization & Referrals section.

To access from the BCBSND website:

Go to www.bcbsnd.com
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

Entering or checking the status of an authorization request is done within Availity Essentials.

NextBlue of North Dakota does not follow the same authorization submission process as BCBSND Commercial or Medicaid Expansion. 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 and/or utilize the BCBSND Payer Spaces guide (requires login to Availity Essentials).

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. 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.

Visit https://www.nextbluend.com/provider-resources to access the NextBlue Provider Manual

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.

The Availity Essentials provider portal allows one claim to be loaded on a direct message. However, BCBSND allows providers to ask about more than one claim at a time within the free form text box.

If referencing more than one claim in a message providers must ensure the claim(s) are related to:

- The same member UMI/plan

- If a member has a primary plan and a secondary plan, the expectation is to send two separate messages. One under each plan number.

- The billing NPI matches on all questioned claims

- The same scenario

- If it is not same issue, the BCBSND advocate may ask for a separate message to be sent.

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

Appeals
- Submit the appeal using our Provider Appeal Form. 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.

For detailed instructions on how to sign up or how to view a remittance advice see Availity Essentials help topics and/or utilize the BCBSND Payer Spaces guide (requires login to Availity Essentials).

ERA enrollment can only be completed by the Availity Essentials assigned administrator or administrator assistant. If you do not have access, please contact your administrator.

You must be enrolled with the appropriate payer ID to view remittances for that line of business.

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.

You can also access the BCBSND Credentialing page by visiting our website.

To sign up for EFT, you must have successfully enrolled for ERA.

You can check your EFT submission progress status at any time within Availity Essentials.

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

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 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.

Additional guidance on how to find your facilities appropriate administrator or employee access can be found within the payer spaces guide or within Availity Essentials resources.

For detailed instructions on who can sign up, how to sign up, EFT status, or to view check information see Availity Essentials help topics and/or utilize the BCBSND Payer Spaces guide (requires login to Availity Essentials).

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

Available Functionality

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