Check Eligibility and Benefits: Don't skip this important first step!
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 benefit preauthorization required for a particular member/service?
Get Answers Up Front
Benefits will vary based on the service being rendered and individual and group policy elections. It is 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 verification, coverage status and applicable copayment, coinsurance and deductible amounts. Also, the benefit quote may include information on applicable benefit preauthorization/prenotification requirements. When it is determined that services may not be covered, you should notify members in writing 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.
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, out-of-area Blue Plans and Federal Employee Program® (FEP®) members.
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 the Educational Webinar page 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.