What's new

Freestanding imaging facilities need to register with OptiNet prior to the site-of-care reviews that begin May 1, 2025.

OptiNet collects service and capability information about outpatient providers, which Carelon Medical Benefits Management (Carelon) will use to determine available sites for MRIs and CTs for our commercial members.

To learn more about the radiology site-of-care program, using the Carelon provider portal and registering with OptiNet, register for a Carelon webinar.

4/1/2025

Additional cardiovascular services delivered to Uniform Medical Plan (UMP) members on or after May 1, 2025, will be subject to pre-authorization review as part of our cardiology program, administered by Carelon Medical Benefits Management (Carelon).

The program reviews outpatient cardiovascular tests, procedures and implantable cardiac devices. Note: Procedures performed in an inpatient setting or on an emergent basis are not subject to this program’s pre-authorization requirements.

You can view the new codes in the Cardiovascular section of the UMP pre-authorization list.

3/26/2025

The code-specific lookup feature for reimbursement schedules is unavailable. While we work to restore this function, please follow these steps to access reimbursement information:

1. Access the Fee Schedule Tool through Availity Essentials
2. Enter your National Provider Identifier (NPI) or tax ID
3. Click the Actions button
4. Select Download entire fee schedule

Note: The Enter Specific Codes function is unavailable. You must download the complete reimbursement schedule to view rates.

We are working with our vendor to restore the code lookup feature and will announce when it is available.

3/13/2025

Availity is currently unable to accept appeals for emergency department (ED) claims reviewed and adjusted as part of our Emergency Department Claim (EDC) Analyzer program with Optum.

Affected claims will have an N22 Alert that states the procedure code was added/changed because it more accurately describes the services rendered.

Q1 2025 standard reimbursement schedules are now available for download on Availity Essentials’ Fee Schedule Tool. To download the quarterly schedule, select the date January 1, 2025 (1/1/2025). The system defaults to today’s date—you must change this to avoid errors.

We appreciate your patience while we resolved the previous production delays.

3/5/2025

You can now submit medical codes and medications covered under medical benefits as separate pre-authorization requests on Availity Essentials, and each request will receive its own unique case identification (ID) number. This will make it easier to track the pre-authorization status of each request on the Authorization/Referral Dashboard.

Previously, pre-authorization requests for medications covered under medical benefits and medical codes were submitted on the same request which created only one case identification (ID) number for the whole submission.

We hope this enhancement makes the pre-authorization process simpler and more efficient. Learn more about Availity’s electronic authorization options.

3/5/2025

When submitting a corrected claim for a BlueCard member, the member’s name must be entered exactly as it appears on their member ID card. If your corrected claim is rejected due to a mismatch in the member's name, you'll receive a response in the Claim Acknowledgement 277CA Loop 2200D > STC segment. This response will include the following codes:

• STC01-1: A3 (Acknowledgement/Returned as unprocessable claim - The claim/encounter has been rejected and has not been entered into the adjudication system.)
• STC01-2: 34 (Subscriber and policyholder name not found.)
• STC01-3: PR (Payer)

If your claim is rejected:

1. Submit an eligibility and benefits inquiry to verify the member's name.
2. Confirm whether:
   • A hyphen is present in the first or last name
   • A middle initial is included in the first name or middle initial field
   • There's a space between names in any field
   • A suffix is present in the last name or suffix field

Following these steps ensures your corrected claim is submitted accurately, reducing the risk of further rejections. Learn more about corrected claims and BlueCard claims submission.

2/18/2025

Industry-wide supply constraints have led Walgreens to limit the amount of GLP-1 medications they'll dispense. They will only dispense one-month supplies of GLP-1 medications in most cases.

Please inform your patients of these restrictions or guide them to alternative in-network pharmacies when needed.

What’s happening with the GLP-1 shortage?

The FDA announced that the GLP-1 medication tirzepatide injection, used to treat type 2 diabetes, is no longer in shortage. But several other GLP-1 products remain in short supply. GLP-1 manufacturers Novo Nordisk and Eli Lilly have invested heavily in expanding their manufacturing capabilities to ease shortages in the coming months.

Express Scripts (ESI) home delivery pharmacy suspended dispensing GLP-1 drugs for members who are new to therapy (NTT) in December 2024. As of February 1, 2025, they have resumed dispensing these medications for NTT members.

2/11/2025