NOTE: The guidelines outlined within this communication are intended to assist in clarifying BCBSIL’s interim approach for managing eligibility and benefit inquiries relative to NPI numbers.

BCBSIL physicians and medical providers utilizing the Availity® portal may have, in certain situations, received out-of-network benefit information instead of in-network benefits. This may have occurred in instances where a provider with a Type I and a Type 2 NPI submitted the transaction for member benefit and eligibility status using a rendering (Type 1) NPI rather than a billing (Type 2) NPI.

The following guidelines have been established to help support and clarify the use of NPI numbers when submitting eligibility and benefits inquiries for BCBSIL members:

• A physician who is a sole proprietor and not in a group or clinic must use their Type 1 NPI
• Physicians associated with a clinic, group or IPA must use the Type 2 NPI for the clinic, group or IPA where services are rendered to ensure any group contracts are recognized
• Radiologists, anesthesiologists and other specialists or medical providers who have an individual practice AND an affiliation with a group/clinic/hospital must use the appropriate NPI of the individual practice OR the group/clinic/hospital to identify the entity that is submitting the claim for reimbursement
• DME suppliers must use the Type 2 NPI for the specific location
• Labs and other ancillary providers must use the Type 2 NPI for the entity
• Facilities must use their Type 2 NPI

These guidelines may also apply to your claim status inquiries. Please note that this approach serves as a guide, but in certain circumstance the inquiry may reflect other specialty benefits if multiple NPI number scenarios apply.

Please contact Availity Client Services at (800) AVAILITY (282-4548) Monday through Friday from 7 a.m. to 6 p.m. CT if you have any questions regarding this communication. 

Please remember that a quote of benefits is not a guarantee of payment and that any claims submitted are subject to the terms of the member’s certificate of coverage and eligibility at the time services are rendered.

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BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by third party vendors mentioned in this article. The vendors are solely responsible for the products or services offered by them. If you have any questions regarding any of the products or services mentioned in this article, you should contact the vendor directly.