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Quickly, Efficiently Manage and Respond to Coding Opportunities Online through the Availity® Provider Portal

June 19, 2018

Reporting current and comprehensive diagnoses information on claims for Blue Cross and Blue Shield of New Mexico (BCBSNM) members is imperative to reflect the quality care and services you provide, as well as to help ensure appropriate benefits are applied.

For members with on- and off-exchange health plans who are subject to quality and risk adjustment, BCBSNM uses multiple resources to help identify conditions our members may have had in the past, or may currently have, which have not been documented in diagnoses codes on claims submitted to BCBSNM during the current calendar year.

BCBSNM often reaches out to providers to help address potential coding gaps and possible treatment opportunities. To help make it easier for providers to respond, the electronic Claim Encounter Reconciliation Application (CERA) is available now through the Availity Portal. This new, easy-to-navigate tool helps streamline quality and risk adjustment medical record request and submission processes by:

  • Providing a more efficient alternative to mailing or faxing medical records;
  • Reducing delays associated with paper submissions; and
  • Lessening in-person visits to retrieve medical records.*

You must be a registered Availity user to access the CERA tool. If you are not a registered Availity user, you can complete the guided online registration process online at no charge by visiting availity.com Learn more about third-party links. Providers who are not Availity users will continue to receive these requests by mail, fax or in-person visits. Mailing and faxing medical records will remain options for providers when responding to requests for quality and risk adjustment purposes.

LEARN MORE ABOUT CERA

  • A CERA tip sheet PDF Document is available on our Provider website for quick reference and navigational assistance. Also refer to Availity’s Getting Started Guide for CERA PDF Document.
  • Registered users may log on to the Availity Portal Learn more about third-party links to for a CERA – Training Demo to view the setup process and get started working with the tool.
  • An on-demand webinar is also available on the Availity Portal Learn more about third-party links – once you log on, look for the Claim Encounter Reconciliation Application (CERA) Recording.

Availity users gain access to many useful tools and resources as well as new payer-provider business solutions. In addition to CERA, providers may complete a wide range of electronic transactions for BCBSNM members via the Availity Portal, such as online verification of patient eligibility and benefits, checking claim status, requesting benefit preauthorization, and more. If you have any questions, contact Availity Client Services at 800-282-4548.

*Note: At this time, electronic medical record request and submission processes through CERA are only available for quality and risk adjustment submissions, and are not available for medical record requests resulting from utilization review activities or the claims adjudication process. BCBSNM anticipates offering additional capabilities throughout 2018.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM. BCBSNM makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.

Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have any questions, please call the number on the member’s ID card.

This material if for educational purposes only and is not intended to be a definitive source for coding claims. Health care providers are instructed to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials.