Provider Tools



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These complimentary online applications can be used to accomplish tasks and gain information. Some of the tools require registration through a third-party vendor portal, as noted—see our E-Commerce Connections menu for vendor registration details.




It is important to verify membership and check coverage details for every patient at every visit, before you administer treatment.

 

To obtain fast, efficient, detailed benefits information for Blue Cross and Blue Shield members, you can use Availity’s Eligibility and Benefits tool. This free online tool can provide you with co-payment, co-insurance, deductible, and other important information.

 

Availity Eligibility and Benefits Tip Sheets

Eligibility and Benefits (General) 

Chiropractic

Family Practice and Internal Medicine

Obstetrics and Gynecology

Oncology

Pediatrics

Physical Therapy

 

You must be registered with Availity  to gain access to this and other online resources offered by Availity.

 

Availity is a registered trademark of Availity, L.L.C., an independent third party vendor that is solely responsible for its products and services.

 

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.


Behavioral health professionals and physicians may obtain benefits information for Blue Cross and Blue Shield members using the Availity® Eligibility and Benefits (E&B) tool. This free online tool can provide you with copayment, coinsurance, deductible, and other important information.

 

For more information on how to navigate this tool, refer to the Behavioral Health Provider Eligibility and Benefits Tip Sheet.  You must be registered with Availity  to gain access to this and other online resources offered by Availity.

 

The Behavioral Health program is available only to those members whose health plans include behavioral health benefits through BCBSIL. Some members may not have outpatient behavioral health management. All behavioral health benefits are subject to the terms and conditions as listed in the member’s benefit plan.

 

Availity is a registered trademark of Availity, L.L.C., an independent third party vendor that is solely responsible for its products and services.


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The Availity® CareCost Estimator (CCE) tool is an online member liability estimator that can help professional providers estimate a patient’s potential out-of-pocket costs in real-time for office and outpatient services provided to BCBSIL members.

 

The CCE is available free of charge to BCBSIL independently contracted providers who are registered with Availity.

 

How does the CCE determine an estimate?

  • It analyzes the patient’s primary diagnosis, procedures performed, available benefits and contractual allowances to calculate an estimate based on the information available at the time the estimate was processed.
  • Actual coverage and member liability amounts are determined when the claim is processed.

The CCE allows your office the option of collecting the member’s share at the point of service. You may not collect an amount greater than the amount listed by the CCE at the time services are rendered. Any overpayments must be refunded to the member within 30 days.

 

For more details, refer to the Availity CareCost Estimator Tip Sheet* . To register with Availity , gain access to the free CCE tool and find out about other options, visit http://www.availity.com/ , or call Availity Client Services at (800) AVAILITY (282-4548) for assistance.

 

Please note: Benefits will be determined once a claim is received by BCBSIL and will be based upon, among other things, the member’s eligibility, benefits, limitations and exclusions and the terms of the member’s certificate of coverage in effect on the date services are rendered.

 

*See the CCE Tip Sheet for a brief list of exceptions.

 

Availity is a registered trademark of Availity, L.L.C., an independent, third-party vendor. Availity is solely responsible for all of its products and services, including CareCost Estimator.


The CareProfile tool uses claim-based information to provide you with a consolidated view of a patient’s health care history at the point of care. This electronic health record can help you identify gaps in care, missed prescription refills and possible drug interactions, and other “clinical flags” and treatment opportunities.

 

A sampling of CareProfile results includes:

  • Demographic patient information, including date of birth, address and phone number
  • Information about the patient’s current primary care physician, if applicable, and other providers visited in the past 24 months
  • Diagnoses and procedures submitted and reflected in the claims records
  • Professional, hospital and emergency room services reflected in the claims records
  • Prescriptions filled, including the class of the drug, total fills, and last date filled
  • Radiological and laboratory services reflected in the claim records

To gain access to the CareProfile tool, you must be registered with Availity® Refer to the Availity CareProfile tip sheet  for additional details.

 

Availity is a registered trademark of Availity, L.L.C., and independent third party vendor.


Our Claim Inquiry Resolution (CIR) tool is available via a tab in our Electronic Refund Management (eRM) system. By providing a method for online assistance with specific inquiries on finalized claims, the CIR tool can help save your staff time by reducing the need for phone calls and written correspondence.

 

Currently, we accept five different types of inquiries through the CIR tool:

  • Medicare/Other Insurance EOB
  • Duplicate Denial
  • Additional Information
  • Corrected Claim
  • Fee Schedule/Pricing Inquiry 

You must be enrolled for eRM in order to gain access to the CIR tool. CIR may not be accessed through our Customer Advocates on the phone.

 

For additional details, refer to the CIR Tip Sheet.


The Claim Research Tool—CRT—offers enhanced, real-time claim status functionality to help you manage and resolve your BCBSIL claims. To gain access to the CRT, you must be registered with Availity® 

 

You can use the CRT to:

  • Search by member ID/group number or claim number
  • Check status of multiple claims in one view
  • View claims for a particular date or date range
  • View claims according to status, such as paid, pended or denied
  • View detailed line level information, such as amount paid, ineligible reason code and description for each service line

For additional details, refer to the CRT tip sheet.

 

Availity is a registered trademark of Availity, L.L.C., and independent third party vendor.


Clear Claim Connection—C3—is a free online reference tool that mirrors the logic behind BCBSIL’s code-auditing software*. You can use C3 to help determine how coding combinations on a particular claim may be evaluated during the adjudication process.

 

To gain access to C3, you must be registered with AvailityTM.. Once you are registered, you may connect directly to C3.

  • Register with Availity  or contact Availity Client Services at (800) AVAILITY (282-4548). 
  • Once on the Availity Website, look for Claims Management/Research Procedure Code Edit to access C3.

*Note: BCBSIL implemented ClaimsXtenTM, a code auditing tool developed by McKesson Information Solutions, Inc. For more information, view the ClaimsXten Frequently Asked Questions (FAQs).

 

Clear Claim Connection and ClaimsXten are trademarks of McKesson Information Solutions, Inc. RealMed is a registered trademark of RealMed Corporation.

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


The Electronic Refund Management (eRM) tool is designed to help simplify overpayment reconciliation and related processes. Among other features, the eRM tool provides:

  • Single sign-on convenience
  • Electronic notification of overpayments
  • Online Inquiry/Dispute/Appeal functionality
  • Option to deduct from future payments
  • Pay by check capability

The eRM tool also includes a Claim Inquiry Resolution (CIR)  function, which enables you to submit a variety of online requests for reconsideration on finalized claims.

 

Prior to accessing eRM:

You must be registered with Availity®  or RealMed®.

  • For Availity registration information, visit www.availity.com, or call Availity Client Services at (800) AVAILITY (282-4548).
  • For RealMed registration information, visit www.realmed.com, or contact the RealMed Customer Service Center at (877) REALMED (732-5633).

Once you’re registered…

Log on to your preferred vendor portal to complete the online onboarding form.

 

Availity Users –

  • Click on the HCSC Refund Management link under the Claims Management tab.
  • If you are unable to access this link, please contact your Primary Access Administrator (PAA). To identify your PAA, click on Who controls my access?
  • Contact Availity Client Services at (800) AVAILITY (282-4548) for assistance, or visit Availity®  for more information.

RealMed Users –

  • Click on the HCSC Financial Management link under the Administration tab.
  • If you are unable to access this link, consult with your RealMed Customer Account Manager, or contact the RealMed Client Support Center at (877) 927-8000. 

Availity is a registered trademark of Availity, L.L.C. RealMed is a registered trademark of RealMed Corporation. Availity, L.L.C. and RealMed Corporation are independent contractors and are solely responsible for their products and services.


Our automated preauthorization tool—iEXCHANGE—supports direct submissions and provides online approval, benefits for inpatient admissions and select outpatient services 24 hours a day, seven days a week – with the exception of every third Sunday of the month when the system will be unavailable from 11 a.m. to 3 p.m. (CT). iEXCHANGE is accessible to physicians, professional providers and facilities contracted with BCBSIL.

 

BCBSIL contracted providers who are registered with Availity can submit electronic preauthorization requests for out-of-area Blue Plan members. For additional information refer to our Pre-Service Review for Out-of-Area Members tip sheet.

 

New User Setup

You will need a User ID, password and iEXCHANGE ID to gain access to the tool.

  • If you are a new employee in an office that already uses iEXCHANGE, contact your office administrator for a new username.
  • If your office is new to iEXCHANGE, you will need to set up an initial administrator account.
  • To set up a new account, you must be a network physician, professional provider or facility within Illinois. If you meet the criteria, complete and submit the online enrollment form.
  • You can access iEXCHANGE directly  or through Availity .

New Account Management

Enrollment confirmation will be sent via email within 10 business days. The assigned User ID is for your office administrator who will also be able to create additional usernames for new staff members. The unique iEXCHANGE ID is your office account number—it is the same for all users in your office. 

  • You will receive a temporary password, which must be changed upon receipt.
  • If you forget your password or it has been compromised, use the Forgot Password option on the iEXCHANGE Provider login page.  Or, ask your office administrator to reset your password for you.
  • If you are the iEXCHANGE office administrator and you need your password reset, complete and submit the iEXCHANGE Password Reset Form.
  • All passwords must be changed every 30 days.

Using iEXCHANGE

The Provider login  can be added to your favorites. Transaction requests include inpatient admission requests and extensions, treatment searches, provider/member searches and select outpatient service requests and extensions.

  • To search by member ID, key the member ID exactly as it appears on the ID card. Name and date of birth search options also are available.
  • Required Data—All fields should be completed for each transaction unless marked “optional.” Short lists can be created by the administrative users for commonly used provider ID numbers, diagnoses and procedure codes.

Support

Tip Sheets

 

Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. Aerial, iExchange and Medecision® are trademarks of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by Availity or Medecision. The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.

 

Please note that verification of eligibility and benefits information, and/or the fact that any pre-service review has been conducted, 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 and the terms of the member’s certificate of coverage applicable on the date services were rendered.


The Member Liability Estimator (MLE) tool can provide you with a real-time, estimated member share amount at the time of service, while the patient is still in your facility, prior to claim submission.

 

This feature enables you to collect copayments, coinsurance and deductible amounts up front, rather than waiting until the claim is processed to reconcile patient accounts.

 

You must be registered with NDAS Online (eCare®)  to gain access to this tool. Already a registered user? Go to the eCare log in page.

 

For additional details, refer to the Institutional MLE Tip Sheet.

 

The Estimator 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, benefits, limitations and exclusions and the terms of the member’s certificate of coverage in effect on the date services are rendered. Accumulated amounts, such as deductibles, may change as additional claims may have been processed after the estimate was provided.

 

eCare is the registered trademark of Nebo Systems, a division of Passport Health Communications, Inc. (Passport/Nebo Systems offers the NDAS Online product to independently contracted BCBSIL providers.) Passport/Nebo Systems is an independent third party vendor that is solely responsible for its products and services.


OptiNet is an online assessment tool developed by American Imaging Management® (AIM®)  to collect modality-specific data from imaging providers. Blue Cross and Blue Shield of Illinois (BCBSIL) is pleased to introduce this tool as an enhancement to our Radiology Quality Initiative (RQI) program, which AIM administers for BCBSIL. The OptiNet assessment process will help facilitate the provision of accurate and consistent information, when needed, to help promote patient safety, accessibility of care, and cost effectiveness. The information on OptiNet is based on information given by high- and low-tech imaging service providers. Areas of assessment include staff qualifications and equipment accreditation. Providers can update their information whenever necessary. 

 

High-tech Imaging Service Providers

If you bill BCBSIL for the technical component of Computed Tomography (CT/CTA), Magnetic Resonance Imaging (MRI/MRA), Nuclear Cardiology or Positron Emission Tomography (PET), you should already have completed AIM’s online OptiNet assessment.

  • Your assessment data will be analyzed to determine a modality score (represented by a letter grade) for each modality you register.
  • High-tech service provider modality scores are available now to ordering providers via AIM’s online directory.
  • The average allowed payment amount for the procedure (based on professional and technical components of previously billed services), along with distance from the member’s home will also be shared to assist ordering physicians with making important health care decisions.

Low-tech Imaging Service Providers

The OptiNet tool is available to collect capability information from providers who perform the technical component of X-ray, ultrasound, echocardiography and mammography services.

  • Your assessment data will be analyzed to determine a score (represented by a letter grade) for each modality you register. (Exception: Modality scores will not be generated for mammography.)
  • Low-tech provider modality scores will not be made available for viewing by ordering providers.
  • Results will be utilized by BCBSIL for reporting and quality enhancement initiatives.

For More Information…

Ready to begin?

Use the link below to register (select “BCBS Illinois” from the drop down menu) and complete the online assessment. You can save your data as you go—no need to complete the assessment in one sitting. Upon completion, you will receive an email confirmation. The OptiNet tool will remain available to you if you need to make changes at a later date. You should update your information as necessary.

 

Access the OptiNet Assessment Tool now! 

 

OptiNet is a registered trademark of AIM, an independent third party vendor that is solely responsible for its products and services. BCBSIL 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 they offer, you should contact the vendor directly.