In case you haven’t discovered this yet, we want to introduce you to the Availity Essentials™ enhanced claim status tabs. They make it quick and easy to find your claims.
Why you’ll want to use these tabs
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Fewer required fields make them more user-friendly than the HIPAA tab (e.g., the Claim Number search has two required fields, the HIPAA search has seven)
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These claim-finder tabs are wired for efficient self-service
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You can save time on phone calls
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Searches on these tabs now return claims for all lines of business
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CHS claim-forwarding status is also now available via these tabs
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Search results include reasons for most pended and denied claims (currently not available for Federal Employee Program® claims)
Learn more ways to save time
You can access live and recorded webinars for your teams through Availity’s Help and Training menu. Go to “Get Trained” and enter “Claim Status” in the search field. If you have questions about using the enhanced claim status tabs, feel free to reach out to the Availity Client Service team at 800-282-4548.
Important updates effective July 1
Standard prior authorization penalty policy change: Partnering with providers through the prior authorization process helps ensure the best clinical outcomes for our members. We’re committed to making the request process easy and efficient for you. To further strengthen prior authorization compliance, we are also updating our standard penalty policy for most AZ Blue commercial plans. For dates of service on and after July 1, when a required prior auth is not obtained, the claim (or claim line) for that service will be denied. Billing the member for the service is not permitted. Get the details.
Expansion of our jointly administered plans: This line of business allows large, self-funded groups to manage their benefit plan through AZ Blue and a third-party administrator (TPA). Starting July 1, seven groups will be switching from their current plan to a jointly administered plan. Medical policy and prior authorization for these groups will be administered by AmeriBen or American Health Group. See a list of prefixes and UM information for these groups.
Prefix list update: We have updated the prefix list to include the new prefixes for groups with jointly administered plans. Preview the updated list. For more information about prefixes and prefix replacements, visit azblue.com/prefix.
Applied behavior analysis (ABA) claim pricing update: In addition to the annual fee schedule updates (see below), we want to let you know about some changes for billing behavior-identification assessments. Effective July 1, we have added new pricing actions for modifiers HN, HO, and HP when appended to CPT codes 97151 through 97158. The HM modifier will continue to pay at 100% of the fee.
Part B step therapy: As new biosimilars and medications are approved by the FDA, we review our Part B step therapy policy for potential updates. For July 1, please see our draft policy highlighting the drug categories that have changes.
Annual fee schedule updates: You can preview the annual fee schedule updates (effective July 1) starting June 1 on the Availity Essentials portal.Read more.
What starts in June
June 16: MCG update
For service dates on and after June 16, we’ll begin using the 30th edition of the MCG care guidelines. To see which ones we use, visit Availity Essentials > Payer Spaces > AZ Blue > Prior Authorization and Medical Policies > AZ Blue Plans.
June 1: Prior authorization changes
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Varicose vein treatments will require prior authorization for all commercial plans: See the codes.
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Five injectable drug codes will require prior auth for all commercial plans (not just plans delegated for EviCore): J0585 through J0589
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One code is no longer eligible for the Gold Card Program: 22840 (posterior non-segmental instrumentation)
June 1: 30-day readmission policy update
Claims for acute care hospital readmissions that occur within 30 days after discharge are reviewed in relation to the initial hospitalization to evaluate the circumstances. Starting June 1, if the readmission is determined to be a continuation of care, and the claim is for the same DRG as the original claim, the claim for the readmission will be denied as included in the primary admission. If the claim is for a similar DRG, it will go through further review by a clinician.
Non-reimbursable modifiers: Certain modifiers indicate that an external funding source holds financial responsibility (i.e., HU, HV, HW, HX, HZ, QJ, SE, SL). AZ Blue will not reimburse for these. See the revised Modifier Pricing Action List.
Other reminders and tips
Don’t forget the barcode! When responding to a records request for a claim, be sure to send a copy of the barcoded request letter we sent you. We need that barcode in order to match your records to the correct claim. Sending records without the barcode letter can lead to unnecessary delays and claim denials.
Records tip for appeals: For quicker turnaround times, please place your grievance form or appeal request cover sheet at the beginning of your submission and send only the documentation that pertains to your appeal (rather than the entire patient record). This will help us quickly identify what you’ve sent as an appeal, so it can be directed to the correct team for review.
90-day window for standard timely filing: As of May 1, our 90-day standard timely filing time frame also applies to FEP claims.
Reporting tip for HEDIS® CBP measure: When an initial blood pressure reading is ≥139/89, we recommend a second reading (later in the same visit) when the patient is more relaxed. This often results in lower and truer numbers. Please capture and report all readings in the patient record. This simple best practice often prevents a HEDIS care gap that would require further attention.
AZ Blue Medicare Advantage plans do cover annual exams: Please note that although our 2026 EOC does not mention annual exams, they are definitely a covered benefit for our Medicare Advantage plans. Go ahead and schedule the exams, and bill us accordingly!
Learning opportunities
Perinatal mental health: Designed to support maternal mental health in Arizona, this free, self-paced training takes you through three one-hour modules to help you deliver compassionate, effective care to this vulnerable population. See course and CE information.
Availity is a separate, independent company contracted with AZ Blue for provider portal services. Availity is a registered service mark and Availity Essentials is a service mark of Availity, LLC.
The MCG care guidelines are the proprietary and copyright-protected information of MCG Health, part of the Hearst Health network.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
Blue Cross, Blue Shield, the Cross and Shield Symbols, Federal Employee Program, and FEP are registered service marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
