Types of Self-ServiceTools and Definitions
Authorizations and Referrals
Quickly request authorizations and referrals, and also check the status or modify an existing request. Enhanced referral feature helps ensure a requesting provider selects a specialist that participates with the specific member plan type when a referral is required.
An electronic alternative to paper-based attachment request process. (Limited pilot)
Claim Status (new)
Review several submitted claims using multiple search parameters.
Claim Status Inquiry
An easy way to check the status of a claim (that was not processed real-time or waiting on a response) and find out information about denied or delayed claims.
Electronic Claim Submission
Submit government and commercial claims quickly and receive claims payment faster.
Eligibility and Benefits (E&B)
Allows providers to electronically verify a patient's eligibility and receive contract benefit information quickly and easily.
Florida Blue Learning and Development
Access Florida Blue training, including on-demand courses and courses in coding.
Provider Data Management tools
Maintain and update your provider information, such as service locations, contact information, providers who join your organization, and when you're accepting new patients.
Real-Time Claim Adjudication
Combines patient financial responsibility information with real-time claim adjudication to provide patient responsibility at time of service. Accessible through CareCalc and claim submission on availity.com.
Patient Cost Estimator (CareCalc)
Use this tool prior to rendering service to determine the exact amount Florida Blue will pay.
Electronic Funds Transfer
Electronic receipt of claim payments deposited directly into the provider's bank account.
Electronic Remittance Advice
Claims remittance advice that is read electronically by the provider's internal Practice Management System.
Track, manage and respond to requests for recovering overpayments. Submit disputes or inquiries; complete and submit forms to resolve requests; retrieve or attach documents; and review overpayment history.
Quality Efficiency Reporting Portal
Allows eligible PCP practices a way to compile data and identify cost, quality, utilization and administrative improvement opportunities.
Remittance Viewer (Remit Reader)
View all of your claim remittances online, eliminating the need for receiving paper remits.
Admit / Discharge / Transfer Viewer
View in real-time: admit, discharge and transfer notices; lab results; and Continuity of Care Documents (CCD).
Care and Coding Reminders
Clinical, claims and pharmacy data is used to display potential gaps in our members' care. These reminders support medical care that may not have been addressed, e.g. mammogram, colonoscopy, flu shot. Care reminders are located within both Eligibility & Benefits and the Patient Care Summary.
Coding gaps are also located within Eligibility & Benefits Care Reminders. Coding gaps are inconsistencies between encounter documentation and claim diagnosis codes, e.g. physician documentation states a diagnosis of diabetes, but the submitted claim does not include a diagnosis code for diabetes.
Clinical Quality Validation Forms
Digital pre-populated form that enables providers to close care gaps. Required for Medicare Advantage.
Comprehensive Quality and Risk Health Assessment Forms
Provides the capability to show known, suspected and dropped conditions that may impact members under a provider's care. Also allows a simplified interface for sending information between providers and Florida Blue to confirm, close or correct coding info. (CQRP assessment forms for patient encounters in 2017 must be submitted by February 28, 2018. All 2018 encounters are handled through the Quality Engagement Program.)
Available to PCPs to review hospital admission, discharge and transfer information for their attributed Florida Blue Medicare HMO and myBlue members.
Submit your clinical or administrative appeals with all supporting documentation, saving time, postage and money. Also track clinical appeal status through the Task List within the tool.
Enhanced Medication Therapy Management
Allows PCPs to receive medication action plans for our Medicare D members who have chronic health conditions. The PCP is able to make adjustments to the medication plans and also refer patients to a specialist if needed.
Medical Records Extract Viewer
Payers can review documentation and request medical record attachments from a provider; providers can fulfill requests for medical records attachments. (Limited pilot)
Patient Care Summary
Assists providers in obtaining patient's history intake at time of service; improves care delivery by recording patient history, avoiding potential medical errors and duplicating therapies; and improves revenue through awareness of gaps to be closed.