Eligibility and benefits
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Verifying eligibility and benefits for a single member
Select the Search single member tab on the Verify eligibility page to determine eligibility and benefits for one Blue Shield of California/Promise Health Plan, other Blue plan, or Federal Employee Program member at a time.
To search for a Blue Shield of California or Promise Health Plan member:
- Choose 'Blue Shield of California / Promise Health Plan' as the card type.
- There are three options for the next step:
- Search by the subscriber ID (9-16 alpha numeric characters) or
- Search by the member's last name, first name, and date of birth or
- Search by the member’s Social security number, Medicare beneficiary number, or Client index number.
- When you’ve completed steps 1 and 2, click Search.
Note: Blue Shield of California subscriber eligibility and benefit information is available for up to 24 months before today’s date and one year before a member’s termination. Eligibility information is updated daily.
To search for other Blue plan or Federal Employee Program (FEP) members:
- Choose the member coverage or card type.
- Select the Member type. The subscriber is the Primary member. A dependent is any family member covered by the subscriber’s plan.
- For the Subscriber, enter the Member ID (9-20 alphanumeric characters), Last name, First name, Birth date, Gender, and Eligibility/service date. For dependents, you must also enter the Subscriber last name.
- Choose your National Provider Identifier (NPI) from the drop-down list. If your NPI is not listed, select NPI not listed, then add your NPI.
- Choose the Service category and Service type to request specific benefit information.
- Click Search.
Tips:
- All search fields are required.
- You can identify an FEP member by the ID prefix R00 to R99.
- Searching other Blue plans and FEP member eligibility involves multiple database queries and may take more time. Once the search is complete, results will be presented on the page and/or in the Message center.
- Other Blue plan and FEP member information is provided by the member’s home plan. The home plan is responsible for the quality and availability of the information.
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Snapshot of a single member’s eligibility
When you conduct a search to verify a single member’s eligibility, the search results provide a snapshot of the member’s eligibility information. This information also appears in the member’s eligibility details.
A Blue Shield of California member’s eligibility snapshot includes:
- Member name
- Subscriber ID
- Eligibility status based on current medical coverage.
- Basic member information: Birth date, Gender, and Residence address
- Coverage information: Plan name, Plan type, Coverage start and end date, Relationship to subscriber, and Subscriber name
- PCP name
- In-network office visit copay information
- Links to Member details, ID card, Benefits, and Claims
A Promise Health Plan member’s eligibility snapshot includes:
- Member name
- Subscriber ID
- Eligibility status based on current medical coverage.
- Basic member information: Birth date, Gender, and Residence address
- Coverage information: plan name, coverage effective date, Redetermination date, Relationship to subscriber, and Subscriber name.
- PCP name and Participating provider group information
- Medicare beneficiary ID and/or Client index number, as applicable
- Links to Member details, ID card, Benefits, and Claims
- Note: If a member doesn’t have current coverage, future-plan information is displayed. If a member has neither current nor future coverage, the latest past plan information is displayed.
Other Blue plan or Federal Employee Program member’s eligibility snapshot includes:
- Member name
- Member ID
- Eligibility status based on current medical coverage.
- Basic member information: Birth date, Gender, and Residence address
- Plan type, Coverage period, and Relationship to subscriber
- Links to Member details, Benefits, and Deductibles/out-of-pocket maximums information
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Verifying eligibility and benefits for multiple Blue Shield of California and Promise Health Plan members
You can search for eligibility and benefits information for up to 10 Blue Shield of California or Promise Health Plan members at a time. Select the Search multiple members tab on the Verify eligibility page. (Multiple search is not available for other Blue plan and FEP members.)
To search for multiple members:
- Enter the Member IDs (9–16 alphanumeric characters) for up to 10 members. Examples:
- XEA123456789,
- J12345678,
- 123456789
- Click Search.
To delete subscriber ID entries individually, click on the eraser icon next to each field. Or you can click Clear form to clear all fields.
- Search results for multiple Blue Shield of California members include the member’s Name, Birth date, Member ID, Relation to subscriber, and links to Member eligibility details and Claims. Benefit information is available from the details page.
- Search results for multiple Promise Health Plan members include the member’s Name, Birth date, Member ID, Line of business (LOB), and links to Member eligibility details and Claims. Benefit information is available from the details page.
Note: Blue Shield of California subscriber eligibility and benefit information is available for up to 24 months before today’s date and one year before a member’s termination. Eligibility information is updated daily.
- Enter the Member IDs (9–16 alphanumeric characters) for up to 10 members. Examples:
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Member eligibility details (Blue Shield of California and Promise Health Plan members)
You can access Blue Shield of California and Promise Health Plan member eligibility details by clicking on the member’s name or the Details link in the search results for single or multiple members.
Member eligibility details contain:
- Member eligibility snapshot, including Subscriber ID and Eligibility status.
- Member information (Phone number, Preferred language, Subscriber dues information for Blue Shield of California members or Federal or state ID number and AID CD/Group information for Promise Health Plan members).
- PCP and IPA/physician group details displaying Current, Future, and Past PCP and physician group information (Address, Phone number, Coverage period, and Provider/group ID).
- Coverage details displaying information for Current, Future, and Past medical coverage for up to 24 months from current date. Coverage details for Blue Shield of California members include Coverage effective period, Plan name, Group number, and Employer name. Coverage details for Promise Health Plan members include Coverage effective period, Plan line of business (LOB), and AID CD/group.
- Deductibles and out-of-pocket maximums are displayed for Current, Future, and Past coverage.
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Deductible and out-of-pocket maximum details
The Deductible and Out-of-pocket maximum details show accumulative and current deductible and out-of-pocket information.
- The Deductible amount is the initial amount members must pay in a calendar year (January 1 through December 31) for certain covered services before they become eligible to receive certain benefits.
- The Out-of-pocket maximum amount is the total amount that a member has to pay in out-of-pocket expenses for covered services received during any calendar year of coverage.
- The Visits accumulator tracks the number of Chiropractic, Acupuncture, and O/P PT, RT, OT and Chiro combined visits that a member has total in their plan year, the number used so far, and the number they have available. Note: this is not applicable for Promise members.
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Benefit details
To see benefit information for Blue Shield of California and Promise Health Plan members, search for the Member, then select the Benefits icon. Benefits information on Provider Connection is formatted to reflect the member’s Evidence of coverage. Find more information about benefits and services for a member’s plan in section 4 of the Medi-Cal Evidence of Coverage (EOC).
Note: You may view current or historical benefits-coverage data by selecting a time period from the Coverage period drop-down.
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Member rosters
This page offers access to the most up-to-date roster of members who have chosen you as their primary care physician (PCP) or medical group.
- Search the roster based on Practice or Provider name. You can also filter by Provider name, Provider address, PIN, or IPA/Medical group.
- Sort by status using the arrow next to the column header.
- Click the Export icon to download a single roster type.
- See which members are new or whose status has changed in the last 30 days.
- View a breakdown of the member roster by attribution status (Active, New, Disenrolled, Redetermined, and On-hold). Click on the count under each status for a detailed member list that can be downloaded and saved to your computer.