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A Provider Workflow

Workflow Step Tool Enables the provider to: Value References
1
Pre-Visit & Scheduling
Eligibility & Benefits (E&B) Inquiry
  • Ensure coverage is active
  • Print a copy of eligibility and benefit results to place in patient’s file.
  • Provides access to Availity Transaction ID (fast path)
  • Streamlines workflow
  • Reduces telephone time
  • Is the gateway to other electronic tools such as Patient Care Summary and CareCalc

 

CareCalc
  • Check for coverage of specific procedures and determine estimated financial responsibility
  • Helps with collections
  • Reduces account receivables
Patient Care Summary
  • View and print two years of the patient’s medical claims history including lab results, hospitalization, prescription history and more
  • Access and print a Patient Care Summary for multiple scheduled patients in batch
  • Complements the physician’s own medical record
  • Streamlines workflow with batch function for scheduled patient visits
Health Care Service Inquiry/Review (Authorization & Referral)
  • Review services to determine whether the definition of medical necessity is met for coverage and payment purposes only under the member’s contract
  • Prevents possible penalties for not obtaining approval
  • Allows providers to receive approval within appropriate timeframes
  • View provider authorizations online
2
Check-in
Eligibility & Benefits (E&B) Inquiry
  • Ensure patient’s coverage has not changed
  • Provides access to Availity Transaction ID (fast path)
  • Saves time
  • Is the gateway to other electronic tools such as Patient Care Summary and CareCalc

 

Card Swipe/Patient Payments
  • Card Swipe populates patient information into Availity transaction pages when patient’s card is swiped through a card reader
  • CareCollect Patient Payments llows providers to swipe credit cards or PIN-less debit cards to easily process payments with minimal data entry. You can also manually enter card information or checking account information.
  • Reduces key strokes
  • Schedules recurring payments
  • Voids and credits payments
  • Performs end-of-day settlements
  • Runs reports of payments processed
CareCalc
  • Determine a patient’s financial responsibility using procedure and diagnosis codes for a patient’s visit
  • Helps with collections at the point of care
  Patient Care Summary
  • Provides an electronic or paper view of the patient’s treatment across providers based on two years of claims history
  • View a patient’s recent health care services (i.e., prescriptions, labs, radiology, immunizations, hospitalizations and more)
  • Gives health services information about new patients
  • Complements the physician’s own medical records
3
Exam
Patient Care Summary
  • Provides an electronic or paper view of the patient’s treatment across providers based on two years of claims history
  • Helps identifies treatment gaps
  • Reduces unnecessary procedures
  • Identifies overuse, under-use or misuse of treatments
Health Care Service Inquiry/Review (Authorization & Referral)
  • Review services to determine whether the definition of medical necessity is met for coverage and payment purposes only under the member’s contract.
  • Prevents possible penalties for not obtaining approval
  • Allows providers to receive approval within appropriate timeframes
  • View provider authorizations online
4
Patient Check-out
CareCalc
  • Determines patient’s estimated financial responsibility using procedure and diagnosis codes the patient received
  • Helps with collections while the patient is still in the office
  • Reduces telephone time
  • Can be printed and shared with patients
Real Time Claim Adjudication
  • Submits a professional quick claim to Florida Blue from CareCalc results; renders a response in minutes
  • Faster claims processing and payment
  • Streamlines claims management
  • Eliminates administrative costs associated with billing, such as postage, paper handling, etc.

 

Card Swipe/Patient Payments
  • Swipe a Florida Blue member's ID card through a card reader and automatically populate Availity transaction pages with the information
  • Eliminates the need to manually key member information
  • Collect patient financial responsibility
5
Billing
Electronic Claim Submission
  • Submit claims quickly and easily online
  • Can use claim submission through current billing system
  • Faster claims processing
  • Quickly identifies claim submission errors
  • Reduces administrative costs
  • Environmentally friendly

 

Claim Reconciliation Tool (CRT)
  • View status of multiple claims submitted to certain payers in various ways (e.g., within a specific date range)
  • Obtain Availity Transaction ID (fast path)
  • Helps manages account receivables
  • Reduces telephone time and administrative costs
6
Claims Follow-up & Payment and Claims Reconciliation
Claim Reconciliation Tool (CRT)
  • View status of multiple claims submitted to certain payers in various ways (e.g., within a specific date range)
  • Provides access to Availity Transaction ID (fast path)
  • Helps manages account receivables
  • Reduces telephone time and administrative costs
Electronic Claims Submission
  • Safely and securely submit and track HIPAA-compliant electronic claims.
  • Allows claims to be paid more quickly
  • Reduces administrative costs
  • Eliminates errors due to illegible or inaccurate information
Electronic Funds Transfer
  • Receive claim payments safely and securely by direct deposit to a designated bank account at the financial institution of your choice.
  • Delivers payments days sooner than paper payments by mail
  • Elimination of lost or stolen checks
  • Increased administrative efficiencies and greater convenience
Electronic Remittance Advice (835)
  • Contains an explanation of claim payments, claim denials and other financial information necessary to reconcile patient accounts online
  • Delivers an ERA days sooner than a paper version
  • HIPAA-AS compliant transaction
  • Secure web-based tool is available 24 hours a day
  • Can be printed via a practice management system or billing software
Remittance Viewer
  • View the electronic version of your remittance advice which includes all claims payment/processing information.  This eliminates the needs for paper RA's.
  • Reduces the time to research remittances (manually versus electronically)
  • Allows for faster receipt of remittance advices.
  • Works in conjunction with electronic funds transfer (EFT) for faster flaims reconciliation.
9/24/2013
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.

Provider Workflow