Eligibility and Benefits Issues

Did You Know…….

• That effective dates of coverage can be verified online? This is in accordance with the Customer Service Toll-Free Access Agreement response letter that each provider should have received. Coverage and eligibility for a specific date can be checked by entering that date in the “Service Date” field on the web site. This method can also be used to verify primary/secondary status for a particular date.

• That out-of-state Blue Cross and Blue Shield contracts should be checked by calling 1-800-676-2583 to obtain the home plan’s telephone number? When these contracts are accessed in the system, the provider should be referred to 1-800-676-2583, due to ITS host benefits. This means the contract is not an Alabama contract. ITS stands for Inter-Plan Teleprocessing Services.

• That general contract benefits can be retrieved online? The Customer Service Toll-Free Access Agreement specifically states that, by signing, the provider agrees to utilize their online system. The only time an exception is made is when the Blue Cross and Blue Shield of Alabama corporate help desk advises that the system is unavailable. However, it is fine to call for clarification of the information found in the benefits. For example, if benefits are accessed and the viewer does not understand or has a specific question about them, Customer Service will assist. Callers need to be prepared to advise the representative of the information found in the benefits and the specific question they have.

• That precertification requirement information is given in the benefits? Generally, precertification is not required for outpatient services. If a contract has special guidelines, the benefits will state that. Providers need to read all benefits for each contract, paying special attention to Second Surgical Opinion (for surgical procedures), Pre-Procedure Review, and Exception Processing. ATTN and EXPP headings should always be reviewed on all contracts, for any benefits, guidelines or limitations that are contract-specific.

Note: Predeterminations are a separate issue. A predetermination is a preauthorization to determine medical necessity that is procedure specific, rather than contract specific. You may also access information that addresses predetermination guidelines, as well as procedures considered non-covered or investigational. Publications, such as ProviderFacts, are available for online access and are searchable.

Last Updated January 2010