Provider Toolkit

What is Availity?

Availity is the exclusive clearinghouse and gateway for Blue Cross, optimizing the flow of information between healthcare professionals, health plans, and other healthcare stakeholders through a secure, collaborative internet-based exchange.

The Availity Health Information Network encompasses administrative, financial, and clinical services, supports both real-time and batch transactions via the web, provides business-to-business (B2B) integration with vendors and facilitates electronic data interchange (EDI).

What is Availity Essentials?

Availity Essentials, the exclusive provider portal for Blue Cross, gives you free, real-time access through your browser. It’s ideal for direct data entry, from eligibility to authorizations to filing claims, and getting remittances.

How do I register?

• Visit the Availity website to register for this free, time-saving tool
  • Registration Demo
  • Registration Steps
• Welcome New User
• Guide for Administrators

What is an Eligibility & Benefits transaction? 
An electronic request and response that allows providers to immediately identify if a patient’s coverage is active and also displays high-level (patient liability) benefit information.

How do I obtain information? 
By submitting an Eligibility & Benefits electronic transaction in Availity Essentials under the Patient Registration tab.

• Eligibility & Benefits instructional guide

What data is required?   

• Local members: Member ID and date of birth. Using name and date of birth can lead to multiple matches, which will result in an error message requiring the addition of the member ID.
• Out-of-state Blue Plan members: Member ID, including prefix and date of birth, are the minimum requirements to route a request to a member’s coverage plan. Some plans also require the member’s first and last name.  
• FEP: Member ID and date of birth are required to route a request to a member’s coverage plan
• MCHS (Medicaid): Member ID, including prefix and date of birth, are the minimum requirements to route a request to a member’s coverage plan. 

What data is returned?

• Member’s active or termed coverage dates
• Member demographics
• Coordination of benefits, if applicable
• Primary care clinic/provider, if applicable
• High level of benefits (patient liability) based on the benefit type submitted on the request

How do I read the returned data? 
Availity Essentials provides a clear breakdown of coverage and benefits information split into two tabs, Patient Information and Coverage and Benefits. 

What if I need more information than the Eligibility & Benefits response provides?
Contact Provider Services via phone or messaging in Availity Essentials

• Local telephone (651) 662-5200
• Toll-free telephone 1-800-662-2745 (BlueCard members 1-800-676-2583)

Blue Cross requires prior authorization (PA) for some covered admissions, continued stays, services, procedures, drugs, and medical devices before they can be covered. Prior authorization is a review and approval before a service happens to determine whether it’s medically necessary and appropriate. Prior authorization needs vary by the type of member health plan.
 
View current prior authorization and notification requirements
    
How do I determine if a prior authorization is required?
Blue Cross has developed a tool to help determine when a prior authorization is required for a procedure, service or supply. The tool is available on Availity Essentials as the first step of the authorization process (commonly referred to as the “Is Authorization Required” tool) and the Blue Cross website.

Inpatient Admission, Concurrent, and Discharge Submission Requirements

Sub-acute/Post-acute care facilities, as referenced in the tables below, include the following: Acute Rehabilitation, Long Term Acute Care (LTAC), Skilled Nursing Facility, Eating Disorder Residential Services, Mental Health Residential Services, and Substance Use Disorders Residential Care.

Minnesota Health Care Programs (MHCP) Families & Children, MNCare, MSC+, and MSHO

* A future communication will be published when concurrent review submission is available in Availity Essentials.
+ A future communication will be published when discharge submission is available in Availity Essentials.
 

Medicare Advantage

Commercial products (excluding FEP)

Federal Employee Program (FEP)

Availity Essentials Authorization Submission Guides

• Medicare Advantage PAN FAQ
• Commercial/Medicare Authorization Submission
• Commercial/Medicare Authorization Submission FAQ

How will I know if there are changes to prior authorization requirements?
Upcoming changes to prior authorizations will be documented in a Provider Bulletin, 60 days prior to the effective date. All Provider Bulletins are published on the first business day of each month.

Questions about Medical Policy should be directed to provider services at (651) 662-5000 or 1-800-262-0820.

Claim Submission

Where do I submit Minnesota claims?
Claims must be filed electronically. Claims may be filed through a provider's clearinghouse, using electronic payer ID 00720 for Commercial and Medicare, or submitted directly on Availity Essentials.  For more information on Availity claim submission, visit Availity Essentials.
  
DDE (direct data entry) and Tertiary (Blue Cross and Blue Shield of Minnesota is third payer) claims are submitted directly in the Availity Essentials portal. Learn more about this process.
    
In general, claims for services provided in Minnesota for members of any Blue Plan should be submitted to Blue Cross and Blue Shield of Minnesota, with the exceptions below.    
   
*Note - FEP (Federal Employee Plan) claims are always submitted to the state where the service is rendered.   
   
Where do I submit Border Provider claims?  
Non-Minnesota Border Providers are identified as Providers located within the first county bordering the state of Minnesota that have a direct contract with Blue Cross and Blue Shield of Minnesota. Border providers are required to file claims directly to Minnesota if the services are rendered to a Blue Cross and Blue Shield of Minnesota member and the services were performed at a border location. All other non-Minnesota Border claims must be submitted to the home plan in the state where services were rendered.     
    
Minnesota Border Providers are identified as providers within Minnesota and within the first county of a surrounding state. If the Minnesota Border Provider holds a contract with the Blue Cross plan in the bordering state, and the member is covered through that bordering state, providers should bill directly to the Blue Cross plan that holds the member's contract. All other claims should be submitted to Blue Cross and Blue Shield of Minnesota.    
   
Ancillary Claims for the provider specialties below have different claim submission requirements:

• Independent Lab: Submit claim to the Blue Plan where the ordering/referring practitioner is located 
• Durable Medical Equipment (DME):  
  • Place of service: Billed to the state where patient resides
  • Pick up at store: Billed to the state where the store is located
• Specialty Pharmacy: For self-administered drugs from specialty pharmacy providers, submit claim to the Blue Plan where the ordering practitioner is located
• Ambulance: Submit claim to the state where the pick-up zip code is located

Replacement Claim

What is a replacement claim?
A replacement claim should be submitted when a non-header data element needs to be changed, added or removed from the original submission.  
   
A void claim and new original claim should be submitted when a header data element needs to be changed, added or removed to the original submission.   
 
Blue Cross follows the Minnesota Administrative Uniformity Committee (AUC) Best Practices guide to determine appropriate actions regarding replacement claims and void/new original. View guide

Claim adjustment requests

What is a claim adjustment? 
Claim adjustments are requested when there are no changes required to the claim. Some examples are:

• Coordination of benefits was confirmed by the member after the claim was denied, and the claim can now be processed.
• An attachment was submitted with a claim; however, the attachment was not reviewed, and the claim was denied for missing information in error.

To request an adjustment, contact Provider Services via phone or submit a message through Availity Essentials. 

What is a claim status?  
A healthcare claim status inquiry and response transaction is a communication between a provider and a payer about a healthcare claim. 

When should a claim status be sent?  
No sooner than three days post-electronic submission acknowledgement.     
  
What if I need more information than the status response provides?

• Local telephone (651) 662-5200   
• Toll-free telephone 1-800-662-2745 (BlueCard members 1-800-676-2853)
• Submit a message through Availity Essentials.  

What is an Electronic Remittance Advice (835)?   
An Electronic Remittance Advice (ERA) is the X12 835 transaction used to electronically send providers the data on how a claim was processed by the payer. The 835/ERA is intended to meet the needs of the healthcare industry for the payment of claims and transfer of remittance information. View the MN AUC companion guide for the 835 transactions.
   
What is the difference between an 835 X12 Electronic Remittance Advice Transaction and the Remittance Viewer application on Availity Essentials?   

• The 835 X12 Transaction is a string of data in a file that can be uploaded to your computer using program software that will automatically post information on how a claim was adjudicated in a payer claims processing system.    
• The Remittance Viewer application, on Availity Essentials, is where you can view information from the 835 X12 transaction in a user-readable format.    

How do I receive the 835 X12 ERA Transaction?   
Your organization’s administrator will need to log in to Availity Essentials and complete the transaction enrollment process. Refer to the Availity Essentials section of this toolkit for assistance or call Availity at 1-800-AVAILITY (1-800-282-4548).   
  
Do I receive my payment with the 835/ERA?    
No, claim payments will be paid through direct deposit (EFT) or a paper check.  

• Learn more about direct deposit (EFT)

What if I don’t receive my payment?    
Contact Blue Cross Provider Services at (651) 662-5200 or 1-800-262-0820.    
  
What if I can’t locate the remittance on Availity Essentials using the Remittance Viewer application?   

• Verify that you have permission to view remittance data with your organization’s access account administrator. If you do not have a user account on Availity Essentials, please refer to the Availity Essentials section of this toolkit.   
• If you have permission, verify that your organization has completed the "manage access" process for the payer you want to review remittances for.    
• Verify your search criteria and date fields with the 835/ERA. For additional information or training, use the help tools within Availity Essentials.   
• If you are still unable to locate the remittance, contact Availity Client Services at 1-800-AVAILITY (1-800-282-4548).

What is a post claim appeal?   
A post claim appeal is a request to review a claim after it has been processed, usually if a provider disagrees with the outcome of the claims processing.  

• All first-level appeals must be received within 90 days of the claims' remit date.  

If I disagree with the claims processing outcome, how do I resolve the issue?
The information below will help you determine next steps for resolution.

An appeal should be submitted when there are no changes needed to the claim and you do not believe the claim processed correctly. Examples of when to submit an appeal:   

• Medical necessity denial on claim, but medical records support medical necessity per the Blue Cross medical policy  
• Pricing of claim does not match expected allowance  
• Claims denied due to coding edit and medical records support the coding submitted on the claim  

A claim adjustment can be requested by calling provider services or submitting a request through the "claims messaging" tool in Availity Essentials.  Examples of when to request a claim adjustment:   

• The member has advised they updated their coordination of benefits and claims need to be reprocessed  
• Information was submitted with a claim, but not used for processing, such as primary insurance information  

A replacement claim should be submitted when a non-header data element needs to be changed or added to the original claim submission. If changing information at the header level of a claim (i.e., patient name, patient identification number, patient date of birth, billing provider information, statement coverage dates, change of type from inpatient to outpatient or vice versa), the original claim must be voided and a new original claim submitted. Blue Cross follows the Minnesota Administrative Uniformity Committee (AUC) Best Practices Guide to determine appropriate actions regarding replacement claims and void/new original.

If a claim is denied for lack of medical records, submit a replacement claim with an Attachment Control Number (ACN) that matches the ACN on the faxed Attachment cover sheet. Fax the Attachment cover sheet, along with the medical records, to 1-800-793-6928. The Attachment coversheet can be accessed on the Minnesota Administrative Uniformity Committee (AUC) site.

Please note that when submitting medical records in response to a request you received via letter from Blue Cross, you must follow the instructions in the letter to submit the requested medical records. 

What do I submit with the appeal?   
Attach any documentation that supports the review of your appeal.   
 
How do I submit my appeal?

• For Minnesota-based Blue Cross and Blue Shield of Minnesota members, submit on Availity Essentials (for additional information, see appeals training video available in Availity Learning Center)
• For non-Minnesota Blue Cross and Blue Shield of Minnesota members, fax to (651) 662-2745.  
• Appeals for all members can also be submitted by mail to:

Blue Cross and Blue Shield of Minnesota  
Attention: Appeals and Grievances Team
PO Box 982800  
El Paso, TX  79998-2800  
  
Appeal FAQ

Pre-Service Appeal

What is a pre-service appeal?
A pre-service appeal is a request for review of a prior authorization denial.  Pre-service appeals must be received within 30 days of the original determination.  

How do I submit a pre-service appeal?

For Minnesota Commercial and Medicare members, fax to (651) 662-9517 or mail to:

Blue Cross and Blue Shield of Minnesota  
Attention: Appeals and Grievances Team
PO Box 982800  
El Paso, TX  79998-2800 

For eviCore determination, fax to 844-324-7007 or mail to:

eviCore Healthcare   
Attn: Appeals   
400 Buckwalter Place Blvd  
Bluffton, SC 29910    
 

What is a managed care referral? 
A managed care referral occurs when a patient’s designated Primary Care Clinic (PCC) authorizes that patient to seek medical care from other providers. A verbal referral is not sufficient. If the PCC authorizes a referral, it needs to be communicated to Blue Cross and Blue Shield of Minnesota, unless a referral bypass is in place.    
 
A referral does not override admission notification/authorization or prior authorization requirements. All services are subject to medical necessity and contract benefits.  
 
When is a managed care referral needed? 
A managed care referral is necessary when care or services required by the patient cannot be provided by the Primary Care Clinic and its affiliates.   

How do I submit a managed care referral?
Most can be submitted in Availity Essentials.

• How to submit a managed care referral.

However, the following types of referrals must be submitted via fax to (651) 662-6860. Referral fax form

• Retro referral for inactive patient  
• Retro referral with change in PCC   
• Referrals with a start date greater than 24 months from current date   
• Referrals to dentists or oral care practitioners   
• Referrals to directory-suppressed practitioners   
• Referrals to out of state practitioners    
• Referrals to out of network practitioners  

How do I submit an inquiry about, or an update to, a previously submitted referral?
Referral inquires and updates can be made in Availity Essentials. 

• How to inquire and/or update a managed care referral

Exceptions
Patients may receive care without a referral from the following specialty providers in the Minnesota Advantage Provider network.   

• Network OB/GYNs can refer members to other network OB/GYN specialists only. All other referrals must come from your primary care clinic.   
• Chiropractors   
• Eyecare specialists (for routine eye care only)  
• Hearing aid providers (for hearing exams and hearing aids once every three years, and for hearing aid accessories)
• Medical suppliers   
• Behavioral health   
• Chemical dependency  

Three types of provider communications are published regularly.   
  
Provider Bulletins communicate contractual changes with a 60-day notice. Examples include changes in prior authorization requirements or changes to reimbursement policies. Provider Bulletins are published on the first business day of each month.   
   
Provider QuickPoints offer updates that are not contractual changes, such as helpful tips, reminders about processes, or changes in pharmacy benefits that do not impact provider liability. QuickPoints may also highlight a change implemented by a national governing body such as the Centers for Medicare & Medicaid Services (CMS). QuickPoints are published on the second and fourth Wednesdays each month.   
   
The Provider Press is a special QuickPoint published quarterly featuring articles on assorted topics, as well as a listing of the medical policies updated within the previous quarter.  The Provider Press is published on the second Wednesday of the month in March, June, September, and December.
   
All provider communications can be found on the Forms and Publications page of the Blue Cross website, and in Availity Essentials under the BCBSMN Payer Spaces – News and Announcements tab. 

What does Provider Services do?
Provider Services connects providers with representatives who can answer questions regarding benefits, claim status, eligibility, contracting and credentialing.    
  
When should I contact Provider Services? 
Provider services should be contacted after exhausting provider self- service options. Self-service options are available through Availity Essentials to check claim and appeal status, member eligibility, and benefit information.    
    
What information will I need to provide when I call?

• Name, facility and NPI number for verification
• Member ID # and member first/last name
• Date of service, claim # (found on Availity Essentials) and claim amount

How do I reach Provider Services?   

• Local telephone (651) 662-5200   
• Toll-free telephone 1-800-262-0820 (BlueCard members 1-800-676-2853)
• Messaging through Availity Essentials 
• If instructed to send a fax by your Provider Services representative, include a cover sheet and send to (651) 662-2745. 

What is Availity Essentials Messaging?  
Availity Essentials Messaging is a self-service option for providers to open an inquiry, ask about a member benefit or inquire about a claim. If you have questions on multiple claims for an individual member, additional claim numbers can be added to your inquiry within the body of the message.      

How do I use Availity Essentials Messaging?  
Registration within Availity Essentials is required to create a sign-on. See instructions under Availity Essentials in the Provider Portal section.    
  
 

What training opportunities are available?    
Blue Cross, along with Availity, offers many opportunities to access resource documents along with live and recorded training sessions through Availity Essentials and the Blue Cross and Blue Shield of Minnesota website.   

• Availity Learning Center 
• Blue Cross and Blue Shield of Minnesota Learning & Development 
• Blue Cross and Blue Shield of Minnesota Education

What is available on the Availity Learning Center?    
The Availity Learning Center includes five sections:    

• Dashboard: Complete your training and access completed courses. Whether you enrolled in free training in the catalog, or purchased training through the store, it’s all displayed on your dashboard.   
• Catalog: Enroll in free product and healthcare training.  
• Resources: Find job aids, handouts and newsletters.   
• Store: Purchase fee-based healthcare training on topics from coding and compliance to office management and business skills, all delivered by industry experts. 
• Forum: Find posts written by our experts to supplement your knowledge.   

How do I access the Availity Learning Center?    
Log in to Availity Essentials. Use the top menu drop-down list to find Help & Training, then choose Get Trained. You will be directed to the catalog of available courses. If you do not have an Availity Essentials user account, sign up here for access. 

 What is available on the Blue Cross and Blue Shield of Minnesota Learning and Development website?    
The Blue Cross Learning & Development website includes three sections:    

• Dashboard: Access courses you have in progress and completed courses. 
• Catalog: Register for upcoming live webinars, view recorded webinars or select on-demand training.    
• Resources: Find job aids, handouts and newsletters. Categories include Quality Measurement Specifications, Risk Adjustment Quick Reference Materials and BCBSMN Helpful Hint documents.   

How do I access the Blue Cross and Blue Shield of Minnesota Learning and Development website?    
Log in to Availity Essentials. Use the top menu drop-down list to find Payer Spaces. Choose the BCBSMN logo. Go to the Resources tab and choose the link labeled Access BCBSMN Learning and Development. If you do not have an Availity Essentials user account, sign up here for access.   
  
What is available in the Blue Cross and Blue Shield of Minnesota Education Center?    
Topics include BlueCard, Blueline phone service, COVID-19/Coronavirus information and Medicare Compliance and Fraud, Waste, Abuse training. There are also links to additional resources, forms, and publications.    
  
How do I access the Blue Cross and Blue Shield of Minnesota Education Center?    
Access the Blue Cross Education Center.