Availity Essentials - Frequently Asked Questions

Is Availity available to providers in all states?
Availity is available in the United States and its territories, however, not all Blue plans contract with Availity.

Can dental providers access Availity?
Yes, Premera Dental is available as a payer through Availity in the United States and its territories.

Is Availity free to use?
Yes. Transactions with any sponsoring health plan (such as Premera) are available through Availity Essentials for free. There are, however, two Availity premium options that charge a fee for access.

Can I submit prior authorizations for Federal Employee Program (FEP) members through Availity Essentials?
FEP members aren't served through Availity for prior authorizations. If you enter an FEP member in the authorization tool, a message will let you know FEP members aren't served through Availity, and you'll see a link to the FEP prior authorization form.

I'm not a provider in Washington or Alaska. Can I use Availity Essentials for Premera prior authorizations by adding Washington or Alaska to my account?
Yes, however, providers outside of Washington or Alaska can use their current Availity state to submit prior authorizations. Premera is listed as a payer for authorizations and referrals in the United States and its territories.

I don't have Premera as one of my payers, does my administrator need to add this to my log in?
If you need a state added, have your Availity Administrator contact Availity Client Services at 800-282-4548, 8 a.m. to 8 p.m. ET Monday through Friday. You can also contact them online by selecting Help & Training > Availity Support.

Can I submit a prior authorization request if my local Blue health plan is contracted with Availity?
Providers outside of Washington or Alaska can use their current Availity state to submit prior authorizations. Premera is listed as a payer for authorizations and referrals in all states. Referrals are for Premera Blue Cross HMO only.

I see multiple out-of-state Premera patients for physical therapy services.
The best practice is to choose the local Blue plan you're contracted with or Other Blue Plans if it's listed in the payer drop down. After entering the patient's information, the system will route you appropriately.

If the local Blue plan you're contracted with for Other Blue Plans isn't listed in the payer drop-down menu, you can add a state by contacting Availity Client Services at 800-282-4548, 8 am-8 pm ET Mon-Fri. You can also contact them online by selecting Help & Training > Availity Support.

How do we get access to other payers on our account?
Payers are automatically added as they roll out new applications in a region (state or territory). If a payer has rolled out an app in your region, but you don't see the payer's name in the payer drop-down menu for that region and app, you can contact Availity Client Services for assistance at 800-282-4548, 8 a.m. to 8 p.m. ET, Monday – Friday.

Once a case is processed, can you view the denial letter on the portal, or at least the reason for denial criteria?
No, not at this time. It will give you a denial and a denial reason and you'll get a separate letter with the denial details.

If a prior authorization request is denied, is the denial letter available in Availity?
No. The denial letter is sent directly to the member and the requesting provider. 

Will Availity provide a denial reason?
Yes, but Availity only provides a high-level denial reason.  The denial letter provides complete details.

Are the denial and approval letters faxed?
Yes, the letters are faxed to the requesting provider.

When a prior authorization is denied, is there an option to appeal through Availity such as a peer-to-peer review or a phone number to call?
Not at this time. Details about appeals are in the denial letters.

Can we appeal through Availity?
Not at this time. Premera requires a signed member authorization for all appeals submitted on the member's behalf. The member appeal form includes an authorization section for the member to sign and date. Providers need to coordinate the submission of appeals with the member as the signed member appeal form must be included with any supporting documentation or medical records relevant to the appeal. Appeals related to contracted rates or provider payments aren't member appeals and don't require member authorization.

On the code check feature if a code requires review, but doesn't need it in certain situations (i.e., some codes don't need review for members under a certain age or when billed with a certain diagnosis) will it alert them of that information or stop them from submitting?
The tool will do auto authorizations based on a specific code and diagnosis being submitted. As for stopping them, the prior authorization process flow won't stop the requester. The requester goes through the process flow and once the request is completed, the request is auto approved. The requester can check the status of the request on the Availity Authorization/Referrals dashboard to see it's approved.

Does the code check tool provide member-specific benefit information for prior authorizations?
The stand-alone code check tool doesn't provide member-specific benefit information (see screenshot below). However, it does include group-specific benefit information. The prior authorization process flow checks to see if a code requires prior authorization and does include member-specific benefit information about the member's referral requirements and out-of-network benefits.

I work at a residential substance abuse facility. We use ICD-10 codes, not procedure codes. How does that work in Availity?
This would be an inpatient prior authorization request and we would accept ICD-10 diagnosis codes.

What happens if you have more than three diagnosis codes?
Currently, the Availity tool only accepts 3 diagnosis codes. If you have more than three, you can include the additional diagnosis codes in the Provider Notes section.

What if I don't have a procedure code to add to my request?
For inpatient notification requests, you don't need to add a procedure code. There will not be one for Lower Level of Care admissions.

What's the difference between Availity and Availity Essentials?
They're the same. Availity, LLC., is the company name. Availity Essentials is the name of the free secure tool portal where you can work electronically with multiple payers through a variety of applications.

Are there ever updates to the Availity portal that I may have missed?  I log in and out all the time.
We have a major release the third Saturday of every month, except November and December. The releases occur on the second weekend of the month. We provide a release blog through Help & Training > Availity Support. You'll also see updates in the News & Announcements section of the payer spaces.

Does Availity show if the member is on a plan or a calendar year?
Benefits could change due to open enrollment periods. Each time the user checks benefits, it does a real-time inquiry which is why we must pull in the date the benefits are verified (the as-of date). The provider can check benefits using a specific date. If the payer returns information about the coverage period, the information displays:

What about our national durable medical equipment (DME) providers (Quest, LabCorp, etc.) who are locally contracted, but serve our patients across the country?
If you communicate with national DME providers who may already be using Availity, you could let them know that Premera is partnered with Availity. If they're signed up with Availity, they can check eligibility and benefits and submit claims. Providers outside of Washington or Alaska can use their current Availity state to submit prior authorizations. Premera is listed as a payer for Authorizations and Referrals in all states.

Is One View Population Health going away?
No. Some providers have access to the Premera One View Population Health platform to view member care and coding gap data and submit data back to Premera related to HEDIS and risk adjustment. If you have access to this platform, you can continue to use it just as you normally do. There is no plan to retire One View. 

Does this mean OneHealthPort (OHP) is going away?
No. OHP remains as our gateway vendor for single sign-on activity. Instead of signing in repeatedly to multiple health plan portals, OHP users sign in just once and get secure authentication for many health plans. The Availity sign-in button is located on the OHP Premera plan splash pages.

Plans served through Availity

• Premera Blue Cross
• Premera Blue Cross HMO
• Premera Blue Cross Blue Shield of Alaska
• LifeWise Assurance Company (Premera affiliate)
• LifeWise Health Plan of Washington (group plans in Clark County)
• Shared Admin and Federal Employee Program (FEP) (except for prior authorization)

Plans NOT served through Availity

• Premera Individual Plans (use Evolent secure portal for Premera WA or AK or LifeWise WA)
• Medicare Advantage Plans (use Advantasure secure portal)

Prior authorizations through Availity aren’t supported for the following Premera plans: Individual, Medicare Advantage, FEP, and some Shared Admin plans. View prior authorization information for those plans here.

Can I initiate an inpatient prior authorization without uploading documentation?
No. We need to be able to review the medical reason for the request.

What about providers who have auto authorization with Premera for specific services? How does that work?
Clinical criteria is built into the prior authorization workflow that recognizes a provider's TIN approved for auto authorization services. The requester goes through the process flow and once the request is completed, the request is auto approved. The requester can check the status of the request on the Availity Authorization/Referrals dashboard to see it's approved.

If there are multiple doctors performing a surgery, can you add a co-surgeon to the prior authorization?
No. The Availity prior authorization workflow includes the requesting provider, rendering provider (or provider providing the service) and facility (if applicable).

If the member becomes active as of May 1, for example, but the provider is trying to submit the authorization in April, are they able to submit the request online?
When a provider enters a prior authorization request, an eligibility and benefits check appears. If the member isn't loaded in our system as an active member, it will return a message that the member isn't eligible.

After a provider sets up an authorization and they want to send additional clinicals, can they come back and attach them after the authorization is submitted?
No. The provider will need to fax any additional documents to Premera. Please include the request's certification reference number on your fax.

Will the tool show you or stop you if the prior authorization request has already been submitted, so that you don't duplicate the request?
No. You'll need to check the Authorization/Referral Dashboard to see what has already been submitted.

Is there a prior authorization form to fill out?
No, the Availity prior authorization tool is an online workflow that walks the requester through the process step-by-step. The steps could be different depending on the type of services requested.

The "rendering provider" is the provider requesting the prior authorization vs. the "servicing provider". Is that correct?
No., the rendering provider is the same as the servicing provider.

Can you edit the servicing provider after it's submitted?
No, once a request is submitted, no additional changes can be made to the request.

Is this limited to prior authorizations or can requests for additional services be completed through Availity?
This is limited to prior authorizations only.

Can a specialist submit a prior authorization or only the primary care provider? Can prior authorizations be retro?
Authorizations for procedures can be submitted by either a specialist or a PCP. They should not be retro as they need to be approved before the service is performed.

Can prior authorization requests be requested for inpatient, outpatient, and specialty office visits?
Office visits would be a referral. Admissions and services are subject to prior authorization.

How can I use the Availity authorization dashboard? Can we filter by CPT code?
No, but you can filter/search by payer, service type, cert number, patient name, dates, etc.

Are the uploads .PDF only?
Availity accepts several different file types. The different types of files are noted on the attachments page. Files must be in doc, docx, gif, htm, jpg, pdf, png, ppt, pptx, tif, txt, xls or xlsx format, no more than 10 files may be added.

Is there an easy way to pin the transaction IDs to my Availity dashboard?
If you're referencing the Availity transaction ID associated with the Authorization Request, this can't be pinned to your Auth/Referral dashboard. Availity Client Services can use other information to locate the prior authorization request if you call for assistance and don't have the transaction ID for the request.

We're an ambulance company that provides air and ground services. We send our records through email and mail to Premera and Premera BlueCard. Are we able to send these records through Availity? If Premera isn't listed, do we need to contact client services?
If you're a WA or AK provider, you can submit your request for air/ground services and attach records with your requests. Providers outside of Washington or Alaska can use their current Availity state to submit prior authorizations. Premera is listed as a payer for authorizations and referrals in the United States and its territories.

Why does the status for my prior authorization request still state 'Pending Review' ?
When you’re viewing your requests on the Authorization/Referral Dashboard page you must click the 'Actions' button and select 'View Details' to refresh your request. This action will send a request to Premera to retrieve and display the current status for your request. Note: We typically respond to electronically submitted requests within 1-2 days, but it can take up to 3 days.

What does the red triangle with the exclamation in the dashboard mean?
This is a message from the payer. If you hover over it, you'll see specific details.

What if both provider sections are the same provider?
Currently, you'll need to enter the provider's NPI again. We'll work on a future enhancement, so you only need to enter it one time.

Will we be able to authorize medications through Availity or is that only for procedures?
Medical drugs such as infusions can be requested in Availity. View all pharmacy drugs requiring approval and how to request approval.

What is the Premera timeframe to complete a prior authorization?
Authorization requests are submitted to Premera in real-time. We typically respond to requests within 1-2 days, but it can take up to 3 days. Check your Auth/Referral Dashboard after submitting the authorization request for status. Note: Don't forget to select the 'Actions' button and select 'View Details' to refresh your request. This action will send a request to Premera to retrieve and display the current status for your request.

Do you need to have the provider on your account to follow up on prior authorization requests?
You can manually enter provider information, so adding them to your account via the Add Providers process on the Manage My Organization page is optional. However, adding them saves you time by choosing them from the Select a Provider drop down which will auto-fill their information.

Do you ever get an automatic approval or do they all pend for review?
Yes, some requests are auto-approved. Some services can be auto-approved based on the provider's TIN or service(s) and diagnosis(es) being requested. After you submit a request, go to the Auth/Referral Dashboard to see that your request is approved.

For the Authorization Inquiry page, how long does it take for a prior authorization completed by phone or fax to be loaded?
We don't take prior authorizations by phone. The speed of loading a faxed request completely depends on the volume of faxes received. Submitting online through Availity gives you a faster response.

How would I submit handwritten notes and/or chart notes with my prior authorization request?
You can upload handwritten notes as a .PDF and attach it to your request. We can accept all types of files, including doc, docx, gif, htm, jpg, pdf, png, ppt, pptx, tif, txt, xls or xlsx.

What number do I call if it says to call the payer/health plan about my prior authorization request?
Call Care Management at 877-342-5258, option 3 (AK: 800-722-4714, option 3).

Can I submit a Premera PCP referral request to a specialist on Availity or is it only for prior authorization requests?
At this time, it's for prior authorizations only. Providers can only submit prior authorizations through Availity for Premera plans. We're not using Availity for PCP referrals, with the exception of Premera Blue Cross HMO.

Referrals for Premera HMO:

An HMO member is required to have a referral for specialty services from their PCP for a specialist or PCP. The referral tool is available in Availity to submit a request for specialty services. There are certain services that are direct access and don't require a referral. View direct access services list.

If an approved referral is not provided and a member chooses to receive services from providers or facilities, those services will not be covered under this plan. The member will be responsible for 100% of the cost for these services and any amount will not apply to their out-of-pocket maximum, except services required by federal or state law. View Availity Referral Tool Quick Reference Guide. Refer to the HMO Plus team customer service experts for referral support or search Find Care for in-network providers.

Note: Premera accepts retrospective requests for Premera Blue Cross HMO referrals up to 6 months after the date of service. 

Does this replace referral authorization submissions via Premera's current secure portal for Premera Medicare Advantage?
Premera Medicare Advantage continues to use Advantasure.

Can I submit a referral through Availity for Microsoft patients?
No, referrals through Availity are for Premera Blue Cross HMO members only. Use the existing referral process as you do today.

Can this be used for retroactive prior authorization submissions?
Prior authorization needs to happen before the service is performed; after that you would submit a claim.

If I have technical issues with Availity, who do I call?
Providers can call Availity Client Services at 800-282-4548, Monday-Friday, 8 a.m. to 8 p.m., ET. Existing Availity users can sign in and select Help & Training > My Support Tickets to submit an online support request or chat online.

What if we try to set up an Availity account and find that one already exists? Does it provide the administrator's name?
For security purposes, no, it doesn't give the administrator's name. To find out who your Availity administrator is, call Availity Client Services at 800-282-4548, Monday-Friday, 8 a.m. to 8 p.m., ET.

Where do I call if I have issues with OneHealthPort?
For OneHealthPort account or log-in questions, call 800-973-4797.

Will we receive an error message or be guided to contact the health plan?
If you receive an error message while using the Availity tools, please reach out to Availity Client Services at 800-282-4548, Monday through Friday, 8 a.m. to 8 p.m. ET. You can also reach them online by selecting Help & Training in the top navigation bar and then selecting Availity Support.

Which Availity tools are available for Premera?

• Eligibility and benefits inquiry
• Claim submission for professional, facility, and dental claims and check claims status (claim submission is free using Premera as the payer)
• C3 Claims Editor
• Remittance viewer – including explanation of payments (EOPs)
• Prior authorization
• Referrals (Premera Blue Cross HMO only)
• Electronic funds transfer - for enrollment and cancelation requests

Which tools remain on Premera’s secure provider portal?
The following tools are not currently supported by Availity and will remain on Premera’s secure provider site. The tools are linked in Availity’s payer space under Resources:

• Payment policies
• PCP roster

Premera’s public provider website for educational resources will remain long-term, even after we’re fully transitioned to Availity. Links to Premera’s non-secure content are accessed through Availity’s Payer Space for Premera business.

Quick Training Videos: Tips for Working with Premera

Our new provider training video series gives you easy access to 2-3 minute videos for quick tips on Availity tools and other important Premera provider information.

Availity Tools:

Adding Washington state as a new region in Availity: Learn how to add Washington state so you can see complete benefits for members.

Finding eligibility and benefits for BlueCard and Shared Administration: Learn how to check eligibility and benefits for BlueCard members and Shared Administration groups.

Electronic funds transfer (EFT): Learn how to sign up for EFT.

Availity tips and resources: Watch a general overview for using Availity secure tools.

If you need general Availity training, visit the Availity training site. You can also contact Training@Availity.com if you have questions specific to training or contact Availity Client Services at 800-282-4548, Monday through Friday, 8 a.m. to 8 p.m. ET.

Update Your Info

Update your information: Learn how to make sure your provider information is up-to-date with Premera.

What about Evolent and Advantasure secure tools?
Premera WA, AK, and LWWA Individual plans will continue to use Evolent tools and Medicare Advantage will continue to use Advantasure tools. Providers will continue to use OneHealthPort's secure single sign-on process to access Evolent, Advantasure, and other health plan provider portals.

Can I submit requests for Carelon (formerly AIM) or eviCore through Availity?
If requesting services through Availity, you'll be directed to complete the request through Carelon or eviCore.

Do I submit prior authorizations through Availity for high-tech imaging?
Most of our imaging is reviewed by Carelon (formerly AIM); if the service requires prior authorization, you'll be directed to Carelon.

For Washington, most of our Premera prior authorization requests for PT and OT go through eviCore after 6 visits. Can we submit through Availity instead, or do we still need to submit through eviCore?
If you submit your requests through eviCore today, you'll continue to submit through eviCore. If requesting services through Availity, you'll be directed to complete the request through Carelon or eviCore.

Do prior authorizations for individual plans go through Availity now?
No, you will need to continue to go through Evolent secure portal for individual plans.

Does everyone have access to Carelon (formerly AIM)? It's not listed on my account.
Carelon is a third-party vendor for certain types of services. If a service is required to be completed by Carelon, you'll be directed by the health plan payer to complete your request through Carelon.

Does Availity alert the user if the code requires review by Carelon (formerly AIM) or eviCore?
Yes. The process flow for prior authorizations includes a check to see if a code requires prior authorization before completing a request. If a code requires prior authorization through Carelon or eviCore, the response will include a message and a link to the Carelon or eviCore website. The requester can't move forward with completing the request through Availity.

Does this mean we no longer go through eviCore for any Premera Blue Cross members?
Prior authorization service requests that go through eviCore today will continue to go through eviCore. 

For radiation services, can I bypass Availity and go directly to Carelon (formerly AIM)?
Yes, you can do a code check and if it's a Carelon code, a link will display to take you directly to the Carelon website.