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Health Care Services Eligibility & Benefits Inquiry
and Response

Eligibility and Benefits Service Type Selections Guide

The Availity ®  Health Information Network Eligibility and Benefits transaction provides documented real time benefits that can be printed and handed to patients. The chart below outlines the benefit categories a registered user can view for each Service Type dropdown selection. When a Service Type option is selected, the corresponding benefit groupings will be displayed by selecting “view additional benefits”. In order to get deductible information you will need to select “view additional benefits” and go to Health Benefit Plan Coverage Service Type.


Drop-down Selection and Description of Service Types Grouping of Related Benefits
Abortion
This service type returns applicable medically necessary benefits related to abortion.
Surgical Benefits-Facility
Surgical Benefits- Professional (Physician)
Health Benefit Plan Coverage
Hospital - Ambulatory Surgical
Allergy
This service type returns applicable benefits related to allergy.
Allergy
Allergy Testing
Health Benefit Plan Coverage
Ambulatory Service Center Facility
This service type will return applicable benefits related to surgical services rendered in an ambulatory service center [includes Radiologist, Anesthesiologist, Pathologist (RAP)].
Hospital - Ambulatory Surgical
Surgical Benefits Facility
Health Benefit Plan Coverage
Anesthesia
This service type will return applicable benefits related to anesthesia [includes Radiologist, Anesthesiologist, Pathologist (RAP)].
Anesthesia
Health Benefit Plan Coverage
Cardiac Rehabilitation
This service type returns applicable benefits related to cardiac rehabilitation (facility and physician).
Cardiac Rehabilitation
Health Benefit Plan Coverage
Chemotherapy
This service type returns applicable benefits related to chemotherapy.
Chemotherapy
Health Benefit Plan Coverage
Chiropractic
This service type returns benefits related to chiropractic services.
Diagnostic X-ray
Health Benefit Plan Coverage
Chiropractic
Spinal Manipulation
Medical Care (ITF)
Dental Care
This service type returns applicable benefits related to dental services covered under the Health product. Dental benefits that are carved out and covered by a plan other than BCBSF would not be returned.
Dental Care
Accidental Dental Care
Health Benefit Plan Coverage
Diagnostic Lab
This service type returns applicable benefits related to laboratory services (facility and physician) for OP, and ICL [includes Radiologist, Anesthesiologist, Pathologist (RAP)].
Diagnostic Lab
Health Benefit Plan Coverage
Diagnostic Medical
This service type returns applicable benefits related to diagnostic services (radiology, pathology, MRI/CAT scan, etc.).
Diagnostic Lab
MRI/CAT Scan
Screening X-ray (Preventative Diagnostic Mammogram)
Diagnostic X-Ray
Mammogram, Low Risk Patient
Mammogram, High Risk Patient
Health Benefit Plan Coverage
Diagnostic X-ray
This service type returns applicable benefits related to diagnostic radiology (facility and physician) for OP and independent diagnostic testing facility [includes Radiologist, Anesthesiologist, Pathologist (RAP)].
Diagnostic X-Ray
Health Benefit Plan Coverage
Screening X-ray (Preventative Diagnostic Mammogram)
Mammogram, Low Risk Patient
Mammogram, High Risk Patient
Dialysis
This service type returns applicable benefits related to renal dialysis (facility and physician).
Dialysis
Health Benefit Plan Coverage
Durable Medical Equipment
This service type returns applicable benefits related to DME.
Durable Medical Equipment Rental
Durable Medical Equipment Purchase
Health Benefit Plan Coverage
Durable Medical Equipment Purchase
This service type returns applicable benefits related to the purchase of DME.
Durable Medical Equipment Purchase
Health Benefit Plan Coverage
Durable Medical Equipment Rental
This service type returns applicable benefits related to the rental of DME.
Durable Medical Equipment Rental
Health Benefit Plan Coverage
Emergency Services
This service type returns applicable benefits related to emergency services (accident, medical emergency) for facility and physician for all locations of service (IP, OP, ER, Office, Convenient Care Centers).
Hospital – Emergency Accident
Hospital – Emergency Medical
Professional (Physician) Hospital
Health Benefit Plan Coverage
Family Planning
This service type returns applicable benefits related to family planning (including contraceptive information).
Family Planning
Health Benefit Plan Coverage
Flu Vaccination
This service type returns applicable benefits related to Flu Vaccination.
Flu Vaccination
Health Benefit Plan Coverage
General Benefits
This service type returns eligibility information only; not benefits.
 
Gynecological
This service type returns applicable medical/surgical benefits related to Gynecological.
Family Planning
Physician Visit - Office: Well (Well Woman)
Physician Visit - Office: Sick
Health Benefit Plan Coverage
Gynecological
Health Benefit Plan Coverage
This service type returns high level benefits for multiple service types.
Urgent Care
Chiropractic
Hospital - Inpatient
Hospital - Outpatient
Hospital - Emergency Medical
Physician - Office: Sick
Physician - Office: Well
Home Health Care
This service type returns applicable benefits related to home health care services.
Home Health Care
Professional (Physician) Visit – Home
Health Benefit Plan Coverage
Hospice
This service type returns applicable benefits related to hospice services.
Hospice
Health Benefit Plan Coverage
Hospital
This service type returns applicable high level benefits related to the facility.
Hospital - Emergency Accident
Hospital - Emergency Medical
Hospital - Ambulatory Surgical
Hospital - Inpatient
Hospital - Outpatient
Hospital – Ambulatory Surgical
This service type returns applicable benefits related to facility ASC surgical services [includes Radiologist, Anesthesiologist, Pathologist (RAP)].
Hospital - Ambulatory Surgical
Health Benefit Plan Coverage
Surgical Benefits - Facility
Hospital – Emergency Accident
This service type returns applicable benefits related to the accident services rendered by the facility (no physician benefits).
Hospital – Emergency Accident
Health Benefit Plan Coverage
Hospital – Emergency Medical
This service type returns applicable benefits related to medical emergency services rendered by the facility (no physician benefits).
Health Benefit Plan Coverage
Hospital – Inpatient
This service type returns applicable inpatient facility and professional benefits.
Health Benefit Plan Coverage
Hospital - Inpatient
Professional (Physician) Visit - Inpatient
Hospital – Outpatient
This service type returns applicable outpatient facility and professional benefits.
Hospital - Emergency Accident
Hospital – Emergency Medical
Immunizations
This service type returns applicable benefits related to immunizations other than Well Child.
Immunizations
Flu Vaccinations
Infertility
This service type returns applicable benefits related to infertility and In-vitro Fertilization.
Infertility
In-vitro Fertilization
In-vitro Fertilization
This service type returns applicable medically necessary benefits related to In-vitro Fertilization.

In-vitro Fertilization
Infertility
Health Benefit Plan Coverage

Licensed Ambulance
This service type will return applicable benefits related to ambulance services.
Licensed Ambulance
Health Benefit Plan Coverage
Mammogram Low Risk
This service type returns applicable benefits related to patients identified with a normal risk for breast cancer and related diseases.
Mammogram Low Risk
Health Benefit Plan Coverage
Mammogram High Risk
This service type returns applicable benefits related to patients identified with a greater than normal risk for breast cancer and related diseases.
Mammogram High Risk
Health Benefit Plan Coverage
Massage Therapy
This service type returns applicable contract level benefits related to massage therapy.
Massage Therapy
Health Benefit Plan Coverage
Maternity
This service type returns applicable benefits related to maternity (facility).
Maternity
Health Benefit Plan Coverage
Medical Care
This service type returns applicable high level benefits for multiple service types.
Surgical
Home Health Care
Hospice
Maternity
Dialysis
Infertility
Skilled Nursing Care
Gynecological
Obstetrical
MRI/CAT Scan
This service type returns applicable facility and professional benefits related to advanced imaging services only.
MRI/CAT Scans
Health Benefit Plan Coverage
Mental Health
This service type returns applicable benefits related to Mental Health.

Note: Mental Health is considered a sensitive benefit and BCBSF is unable to return the accumulated dollar amount maximums or return the number visits used.

Health Benefit Plan Coverage
Mental Health Facility - Inpatient
Mental Health Provider - Inpatient
Mental Health Provider - Outpatient
Mental Health Facility - Outpatient
Mental Health Facility - Inpatient
This service type returns applicable IP facility benefits related to Mental Health.

Note: Mental Health is considered a sensitive benefit and BCBSF is unable to return the accumulated dollar amount maximums or return the number visits used.

Mental Health Facility - Inpatient
Health Benefit Plan Coverage
Mental Health Facility - Outpatient
This service type returns applicable OP facility benefits related to Mental Health.

Note: Mental Health is considered a sensitive benefit and BCBSF is unable to return the accumulated dollar amount maximums or return the number visits used

Mental Health Facility - Outpatient
Health Benefit Plan Coverage
Mental Health Provider - Inpatient
This service type returns applicable IP professional benefits related to Mental Health.

Note: Mental Health is considered a sensitive benefit and BCBSF is unable to return the accumulated dollar amount maximums or return the number visits used.

Mental Health Provider - Inpatient
Health Benefit Plan Coverage
Mental Health Provider - Outpatient
This service type returns applicable OP professional benefits related to Mental Health, including office services.

Note: Mental Health is considered a sensitive benefit and BCBSF is unable to return the accumulated dollar amount maximums or return the number visits used.

Mental Health Provider - Outpatient
Health Benefit Plan Coverage
Newborn Care
This service type returns applicable benefits related to newborn care.
Newborn Care
Nursery
Health Benefit Plan Coverage
Occupational Therapy
This service type returns applicable benefits related to occupational therapy.
Occupational Therapy
Health Benefit Plan Coverage
Oral Surgery
This service type returns applicable benefits related to medically necessary oral surgery services.
Oral Surgery
Dental Accident
Health Benefit Plan Coverage
Obstetrical
This service type returns applicable benefits typically rendered in the office (including specialist copay).

Note: This service type returns applicable benefits related to Adult Wellness/Well Woman.

Obstetrical
Health Benefit Plan Coverage
Obstetrical/Gynecological
This service type returns applicable benefits typically rendered in the office (including specialist copay).

Note: This service type returns applicable benefits related to Adult Wellness/Well Woman.

Family Planning
Physician Visit - Office: Well
Health Benefit Plan Coverage
Gynecological
Obstetrical
Pediatric
This service type returns applicable benefits related to pediatric (well or sick).

Note: If applicable, for autism benefits select the View More menu and select Medical Care.

Pediatric
Well Baby Care
New Born Care
Pharmacy
This service type returns applicable benefits related to prescription drug coverage.
Brand Name Prescription Drug
Generic Prescription Drug
Mail Order Prescription Drug
Pharmacy
Podiatry
This benefit type returns applicable benefits related to podiatry.
Podiatry
Health Benefit Plan Coverage
Professional (Physician) Visit – Home
This service type returns applicable benefits typically rendered in the home.
eVisit (Consultations)
Professional (Physician) Visit – Home
Health Benefit Plan Coverage
Professional (Physician) Visit – Inpatient
This service type returns applicable benefits typically rendered in an inpatient setting.
Professional (Physician) Visit – Inpatient
Health Benefit Plan Coverage
Professional (Physician) Visit – Office
This service type returns applicable benefits typically rendered in the office (including specialist copay).

Note: If applicable, for autism benefits select the View More drop down menu and select Medical Care

Professional (Physician) Visit – Office
eVisit (Consultations)
Other Medical (Medical Pharmacy)
Convenient Care
Physician Visit - Office: Sick
Physician Visit - Office: Well
Health Benefit Plan Coverage
Professional (Physician) Visit – Outpatient
This service type returns applicable benefits typically rendered in an outpatient setting.
Professional (Physician) Visit – Outpatient
Physician Visit – Office: Sick
This service type returns applicable benefits related to an office visit.
Health Benefit Plan Coverage
Physician Visit - Office: Sick
Consultations (eVisits)
Other Medical (Medical Pharmacy)
Physician Visit – Office: Well
This service type returns applicable benefits related to wellness (Adult Wellness, Well Woman, Well Child, Routine Colonoscopy).

Note: If applicable, for autism benefits select the View More drop down menu and select Medical Care.

Physician Visit - Office: Well
Health Benefit Plan Coverage
Physical Therapy
This service type returns applicable facility and professional benefits related to physical therapy rendered at any location of service.
Physical Therapy
Health Benefit Plan Coverage

Physical Medicine

This service type returns applicable benefits related to physical therapy (includes modalities and limitations.

Chiropractic (number of visits)

Diagnostic X-ray

Physical Therapy

Modalities​

Psychiatric Inpatient

This service type returns covered/non-covered; active/inactive ​

Health Benefit Plan Coverage​

Psychiatric Outpatient

This service type returns covered/non-covered; active/inactive​

Health Benefit Plan Coverage​

Psychotherapy

This service type returns covered/non-covered; active/inactive​

Health Benefit Plan Coverage​
Radiation Therapy
This service type returns applicable benefits related to radiation therapy (facility and physician). For specific information see Medical Coverage Guidelines.
Radiation Therapy
Health Benefit Plan Coverage
Rehabilitation
This service type returns applicable facility and professional benefits related to general therapy services such as copays, deductible, coinsurance and benefit maximums.

Note: If looking for a specific therapy, select the applicable Service Type.

Rehabilitation
Health Benefit Plan Coverage
Routine Physical
This service type returns applicable benefits related to Adult Wellness/Well Woman/Colonoscopy.
Routine Physical
Health Benefit Plan Coverage
Screening X-ray (Preventative Diagnostic Mammogram)
Screening Laboratory
This service type returns applicable benefits related to laboratory services, provided for the purpose of preventative care or facilitation of treatment.
Screening Laboratory
Health Benefit Plan Coverage
Screening X-ray
This service type returns applicable benefits related to diagnostic x-ray services, provided for the purpose of preventative care or facilitation of treatment.
Screening X-ray
Health Benefit Plan Coverage
Second Surgical Opinion
This service type returns applicable benefits related to second or third surgical opinions. [Specialty copay is returned on the Professional (Physician) Visit – Office service type.]
Second Surgical Opinion
Third Surgical Opinion
Health Benefit Plan Coverage
Skilled Nursing Care
This service type returns applicable benefits related to skilled nursing.
Professional (Physician) Visit – Skilled Nursing
Skilled Nursing Care
Skilled Nursing Care – Room and Board
Health Benefit Plan Coverage
Speech Therapy
This service type returns applicable benefits related to speech therapy.
Speech Therapy
Health Benefit Plan Coverage
Substance Abuse
This service type returns applicable physician benefits related to substance abuse (alcohol, drug or both).
Substance Abuse
Health Benefit Plan Coverage
Substance Abuse Facility – Inpatient
This service type returns applicable IP facility benefits related to substance abuse (alcohol, drug or both).
Substance Abuse Facility Inpatient
Health Benefit Plan Coverage
Substance Abuse Facility – Outpatient
This service type returns applicable OP facility benefits related to substance abuse (alcohol, drug or both).
Substance Abuse Facility – Outpatient
Health Benefit Plan Coverage
Surgical
This service type returns applicable facility and professional benefits related to surgical services for all locations of service.
Surgical
Hospital - Inpatient
Surgical Benefits - Professional (Physician)
Surgical Benefits - Facility
Anesthesia
Second Surgical Opinion
Third Surgical Opinion
Surgical Assistance
Health Benefit Plan Coverage
Surgical Benefits – Professional (Physician)
This service type returns applicable benefits related to surgical services by a physician for all locations of service
Surgical Benefits – Professional (Physician)
Health Benefit Plan Coverage
Surgical Benefits – Facility
This service type returns applicable benefits related to surgical services by a facility for all locations of service
Surgical Benefits – Facility
Health Benefit Plan Coverage
Surgical Assistance
This service type returns applicable benefits related to surgical assistant.
Surgical Assistance
Health Benefit Plan Coverage
Transplants
This service type returns applicable benefits related to organ transplants (facility and physician).
Transplants
Health Benefit Plan Coverage
Urgent Care
This service type returns applicable benefits related to urgent care services.
Urgent Care
Health Benefit Plan Coverage
Vision (Optometry)
This service type returns applicable benefits related to optometry services covered under the Health Product.

Note: Vision benefits that are carved out and covered by a plan other than BCBSF would not be returned.

Vision (Optometry)
Well Baby Care
This service type returns applicable benefits related to well-baby and well-child care.
Immunizations (Routine)
Pediatric (Well)
  • Contract level deductible amounts, if applicable can be viewed by selecting a specific service type, then View Additional Benefits, then Health Benefit Plan Coverage. Medical Coverage Guidelines and BCBSF Products and Plans which contains a provider manual for Blue can be accessed through a link on the bottom of the Eligibility and Benefits result screen.
  • Additional information can be found in the Plan/Product section.
  • Benefits are provided for Blue Cross and Blue Shield Florida (BCBSF), BlueCard and FEP members.
  • The Eligibility and Benefits results screen provides access to CareCalc, CareProfile and CareCollect.

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Key it Right the First Time in the Eligibility & Benefits Inquiry Screen

The Eligibility & Benefits Inquiry and Response transaction in Availity allows providers to electronically verify BCBSF member contract benefit information in a matter of minutes. However, keying information incorrectly can cause delays in receiving the information you need.

Streamline the way you key and submit an Eligibility & Benefits (E&B) Inquiry by following a few simple guidelines.

  • Take time to be precise. Using shortcuts can cause keying errors, resulting in the need to re-keying or submit information multiple times.
  • Be certain to key member’s data correctly the first time. Keying the member’s data exactly as it appears on their ID card ensures an accurate response.
    • Type the Patient ID number (including the alpha prefix), Patient Last Name, and Patient First Name exactly as they appear on the ID card. (Please note: no middle initial is required.)
    • Please do not use social security numbers in the Patient ID field.
    • Enter the Patient Date of Birth using the MM/DD/YYYY format. Any other format will cause an error. Obtain a copy of the patient’s driver’s license to verify date of birth.
  • Confirm you have the most up-to-date dependent health insurance information before entering and submitting an E&B transaction
  • Please allow sufficient time for newborns to be added to our enrollment system. This can take up to an average of 30-days. If a newborn’s information is not returned after this time, call the card holder and request he/she contact their benefit administrator.
Helpful Hints
  • Swiping the member’s ID card through a magnetic card reader will automatically populate applicable patient information accurately the first time and eliminate key strokes. Card readers can be purchased at many business retailers, office supply stores and can be found online by searching for "magnetic card reader." The card readers must adhere to the following specifications:
    • Capable of reading tracks one, two, and three on a magnetic stripe.
    • Connects to your computer using a USB cable. Note that a separate power cord is not needed. The reader receives power from the computer through the USB cable.
    • It must be a keyboard emulation device.
  • Copy the member’s insurance card at the initial visit so it can be used as a reference on subsequent visits.
  • Copy the member’s driver’s license and use it to verify date of birth.
  • When given information over the phone, verify the information is captured correctly.
  • When referring the member to a specialist, provide a copy of the member’s health insurance card to the specialty group (e.g. anesthesiologists and/or laboratories).

If you continue to receive E&B errors, please contact the member to validate their information.

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7/22/2013
The Manual is not intended to be a complete statement of all BCBSF polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and BCBSF or Health Options the terms of such agreement(s) shall govern.

The Manual is not intended to be a complete statement of all Florida Blue polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and Florida Blue or Health Options the terms of such agreement(s) shall govern.

Refer to the References section to view all applicable copyrights, registered trademarks, service marks, and/or references. Acronyms are also defined in the References section.

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© 2012 Florida Blue is a trade name of Blue Cross and Blue Shield of Florida Inc., an Independent Licensee of the Blue Cross and Blue Shield Association.