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Verifying Benefits and Eligibility

Many individuals may have health insurance for the first time and others are moving from one type of plan to another. It is more important than ever for you to verify benefits and eligibility.

Here are some benefits of doing so:

Help ensure your patients are covered at the network rate.
BlueCross plans sold through the Marketplace may be available in any of the three following networks:

  • Blue Network E – Essential – Available in four service regions.
  • Blue Networks S – Select – Available statewide.
  • Blue Network P – Preferred – Available statewide.

It is extremely important that members who have purchased plans using Blue Network E receive services from a Blue Network E provider in one of the four service regions (Chattanooga, Knoxville, Memphis or Nashville); otherwise, they will pay out-of-network rates. Verifying your patients’ benefits and eligibility will help ensure your patients have selected Marketplace plans that utilize the network(s) for which you are contracted.

Know if your patients are current with their premium payments. When you call BlueCross to verify benefits, we’ll let you know if our member has any unpaid premiums; if so, we’ll indicate there is an administrative hold on their account. Because of possible contract changes or policy cancellations, a final determination of benefits will be made when BlueCross receives claims. Claims will be pended for those members who are within the three-month grace period. BlueCross will send your remittance advice with the following explanation: “This claim was pended due to non-payment of premium and will be denied if the premium is not paid by the end of the grace period.”

Once our member makes a payment, you will not need to call BlueCross to ensure your claims are paid. We will initiate payment once the premium is paid in full.

There are several ways you can easily verify benefits and eligibility.

  • Log on to Availity®, our secure provider portal
  • Call Provider Service at 1-800-924-7141