Download Availity benefit tips - Asuris Northwest Health

Accessing benefits in the
Availity Portal
Use the tips in this flyer as a resource when accessing benefits information
in the Availity Portal, availity.com.
Benefit tips
Benefits showing “Active” or “Inactive”
An Active or Inactive for a specific Benefit Service Type (BST) indicates whether the member’s
health plan does or does not have that benefit (e.g., vision [optometry], dental care, mental
health, pharmacy).
To obtain benefit details for Active benefits:
1. Edit your inquiry.
2. Review the list of BSTs in the Benefit/Service Type drop-down box.
3. Select the BST for the appropriate benefit details.
Chiropractic and acupuncture
If there is no specific information included in the Chiropractic or Acupuncture BSTs, take note that
the Affordable Care Act (ACA) includes a provision prohibiting health insurance companies from
discriminating against any health care provider.
Under this provision, providers who are acting within their scope of practice and in compliance with
their state licensure requirements can provide services to members. If a provider performs a service
that is a covered service under the member’s policy, the service will be covered at the in-network or
out-of-network benefit level, depending on the provider’s participating network status.
Dental
• Accident
• Maxillofacial prosthetics
• Prosthodontics
• Adjunctive
• Oral surgery
• Restorative
• Crowns
• Orthodontics
• Routine/preventive
• Endodontics
• Periodontics
Dental benefit
Access this BST
Preventive and diagnostic services
Routine (Preventive)
Basic services
Restorative
Major services
Crowns
For more detailed dental benefit information, click on Benefit Booklet and select the Dental Benefit
Booklet PDF.
Massage therapy
To obtain massage therapy benefits, select the Physical Therapy BST. Notes:
• We cover physical therapy by licensed massage therapists and other licensed providers under
the patient’s rehabilitation benefit.
• Some of our custom groups have a special massage therapy-specific benefit and/or limit.
For those groups, it is listed separately under the Physical Therapy BST with a MASSAGE
THERAPY message.
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February 2017
Mental health and chemical dependency
The Mental Health BST includes the following
benefit details:
Benefits with copayments
1. The copayment amount will be listed for the service and
provider type.
• Mental Health (Active/Inactive)
2. Deductible and coinsurance amounts apply if coinsurance
is indicated in addition to copayment. Note: If deductible
does not apply, the deductible amount will show below it
as $0.00 Calendar Year.
• Mental Health Facility - Inpatient
• Mental Health Facility - Outpatient
• Mental Health Provider - Inpatient
• Mental Health Provider – Outpatient
Example: After $100 copayment, the deductible applies
until it is met then 20% coinsurance applies.
Chemical dependency benefits can be found under the
Substance Abuse BSTs:
• Substance Abuse Facility – Inpatient
• Substance Abuse Facility – Outpatient
• Substance Abuse (Provider – in-network,
Preferred - in-network, Participating - out-of-network)
Physical therapy
Benefit limits that indicate days per calendar year apply
to inpatient services, while limits that indicate visits
per calendar year apply to outpatient and
professional services.
Vision (routine exam and hardware)
Select Vision (Optometry) to learn if the member does
(Active) or does not (Inactive) have vision coverage.
To obtain routine vision benefit details for members
with active coverage, edit the inquiry, then:
• Select Routine Exam (Vision) for the examination
benefit and frequency limit.
• Select Lenses for the glasses lens and contact
lens benefit.
• Select Frames for the glasses frames benefit if
“Combined Lens/Frames Limit” is not indicated.
Co-payment, deductible, co-insurance and
payment order
Deductible and out-of-pocket information is found in
the Health Benefit Plan Coverage BST.
For plans with deductible and coinsurance:
• When a BST has coinsurance only listed, the
deductible amount must first be met before
coinsurance applies.
• If the deductible does not apply first, the
coinsurance amount will be listed and the
deductible amount will show below it as $0.00
Calendar Year. Example:
© 2017 Asuris Northwest Health
Tiered benefits
Many of our groups have tiered benefit plans and the
benefit changes depending on the provider’s contract status
(participating or non-participating).
• Tier 1 benefits are applicable when the member sees
a provider that is in-network for his or her plan (e.g., a
provider that is contracted with the Preferred network for
a PPO product.)
• Tier 2 benefits are applicable when the member receives
services from a participating provider.
• Tier 3 benefits are applicable when the member
receives services from a provider who is out of
network (a non-contracted provider.)
If a separate tier 2 benefit (participating provider) is not
listed, then the in-network benefit applies to both preferred
and participating providers. Example: