Check Eligibility and Benefits: Don’t skip this step!

April 17, 2020

Is your patient’s membership with Blue Cross and Blue Shield of Texas (BCBSTX) still active? Are you or your practice/medical group in- or out-of-network for a specific patient? Is prior authorization required for a service?

Get Answers Up Front

Benefits will vary based on the service being rendered and individual and group policy elections. It’s imperative to check eligibility and benefits for each patient before every scheduled appointment. Eligibility and benefit quotes include important information about the patients’ benefits, such as membership, coverage status and applicable copayment, coinsurance and deductible amounts. Also, the benefit quote may include information on applicable benefit prior authorization/pre-notification requirements. When services may not be covered, you should notify members that they may be billed directly.

Don’t Take Chances

Ask to see the member’s BCBSTX ID card for current information. Also ask for a driver’s license or other photo ID to help guard against medical identity theft. Remind your patients to call the number on their BCBSTX card if they have questions about their benefits.

Use Online Options

We encourage you to check eligibility and benefits via an electronic 270 transaction through the Availity® Provider Portal or your preferred vendor portal. You may conduct electronic eligibility and benefits inquiries for local BCBSTX members and out-of-area Blue Plan and Federal Employee Program® (FEP®) members.

Learn More

For more information, such as a library of online transaction tip sheets organized by specialty, refer to the Eligibility and Benefits section of our provider website. BCBSTX also offers educational webinars with an emphasis on electronic transactions, including eligibility and benefits inquiries. Refer to Educational Webinar/Workshop Sessions for upcoming webinar dates, times and registration links to sign up now.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.

Checking eligibility and benefits and/or obtaining preauthorization is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and their health care provider.