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Eligibility and Benefits

Patient eligibility and benefits should be verified prior to every scheduled appointment. Eligibility and benefit quotes include membership verification, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. It’s strongly recommended that providers ask to see the member’s ID card for current information and photo ID in order to guard against medical identity theft. When services may not be covered, members should be notified that they may be billed directly.

Checking Online

Providers are strongly encouraged to use availity.com or their preferred vendor for eligibility and benefit verifications. With Availity’s Eligibility and Benefits Inquiry, users can access printable results that include up to date benefit information.

  • Patient/Subscriber information
  • Group Number
  • Group Name
  • Plan/Product
  • Current Effective Dates*
  • Copayment*
  • Deductible (original and remaining amounts)
  • Out-of-pocket (original and remaining amounts)
  • Coinsurance
  • Limitations/Maximums*
  • Preauthorization Indicators and Contacts

For some patients, your Web transactions may instruct you to call Provider Customer Service to obtain benefit details. Our staff remains available to assist with these benefit inquiries as needed.

* These benefit categories will only appear if applicable to the services being rendered.

Checking via Telephone

If you cannot submit your eligibility and benefit inquiries online, this information can also be easily obtained through our Interactive Voice Response (IVR) automated phone system at 800-451-0287, available Monday through Friday, 6 a.m. to 11:30 p.m., CT, and Saturday, 6 a.m. to 3:30 p.m., CT.

Exceptions

For out-of-state Blue Cross and Blue Shield members, call the BlueCard® Eligibility Line at 800-676-BLUE (2583) for eligibility and benefit verifications.  Learn more about BlueCard
For Federal Employee Program (FEP) members, eligibility and benefits can be obtained by calling 800-442-4607.

Questions

Email our Provider Education Consultants. Be sure to include your name, direct contact information, tax ID or billing NPI.

Verification of eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility, any claims received during the interim period and the terms of the member’s certificate of coverage applicable on the date services were rendered.

Availity is a registered trademark of Availity, LLC. Availity is a partially owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an independent licensee of the Blue Cross and Blue Shield Association. Availity operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX, a Division of HCSC. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors. If you have any questions about the products or services offered by such vendors, you should contact the vendors directly.