Improve collaboration with your providers
Providers need access to the most up-to-date payer information available to avoid denials and collect the appropriate payment from the patient. The Patient Management workflow includes the following:
- Eligibility and benefits: Quickly check whether a patient has coverage, if the provider is in network, and the patient’s coverage for all participating payers.
- Member ID card: Download and print a copy of the patient’s insurance ID card.
- Care reminders: Receive notification when a patient has an outstanding service.
- Additional benefit information: Receive payer information that’s not included within the x12 271 response.
- Patient cost estimator: Provide the patient with and estimate of the service.
The claims management workflow allows providers to submit and track claims electronically, reducing calls to your call center and eliminating the need for fax and mail.
- Claim submission: Submit individual claims through the Portal user interface or multiple claims via a batch file.
- Claims correction: Correct a claim that’s already been submitted.
- Claim status: Check to see if the claim has been adjudicated or if any additional documentation is needed.
- Overpayment and appeal: Respond to a payer’s request with appropriate documentation or initiate a denial appeal.
You can deliver the Electronic Remittance Advice (ERA) or 835 data to providers through the remittance viewer tool. Providers can research claims and payments, and because the data is in a human-readable format, rather than ANSI code, it’s easy for non-technical people to understand.
Provider Information Management
Keeping provider information current is a challenge, but Availity’s Provider Data Management (PDM) is designed to help you do just that by letting providers update demographic information through Availity Essentials. Learn more.
Essentials offers multiple channels in which to share information with providers, reducing calls into the call center and prompting providers to take an action.
- Messaging: Allows a provider to initiate a one-to-one, online discussion with a payer representative.
- Notifications: Generates a targeted communication that providers see when logging into Essentials.
- Promotions: Delivers a banner ad highlighting a payer initiative.
- News and announcements: Communicates important, time-sensitive information to providers on the main Essentials page.
Authorization and Referral Management
Essentials helps you streamline the authorization process by giving providers a central location where they can check if an authorization is needed, submit the authorization with required documentation, and manage it all through a user-friendly dashboard.
While Essentials is a multi-payer tool, health plans still need a place to host proprietary, plan-specific information or tools. Payer Spaces gives you a secure location—branded with your organization’s logo—where providers can access this information.
Availity 360 uses administrative data, transactional data and other Portal activity to give you a clear picture of the network’s health. With Availity 360, you can identify trends and drill down into performance metrics based on payer, transaction type, and more.
Looking to do more with Essentials? View our Clinical Gateway capabilities.
Essentials + Clinical Gateway capabilities
Medical Record Exchange
Both health plans and providers want to stop sending faxes and mailing letters. The cost is enormous, the administration is cumbersome and frustrating, and there’s no quality standard or consistent format. That’s why providers use Essentials to send clinical information and medical records, track and respond to requests over time, filter and sort their records, and manage to due dates.
Primary Care Physician Notification
Health plans need to communicate with providers when they receive notifications of admission. Our Primary Care Physician Notification alerts providers of a hospital admission via Essentials, and sends clinical messages through Essentials’ Clinical Viewer. This means the provider can be more accountable for the member’s care, can follow up after discharge, reconcile medications, reduce costs, and improve outcomes.
Clinical Quality Validation
Meeting quality measures requires clear and efficient communication between the health plan and the provider. With Clinical Quality Validation, a health plan can use Essentials to notify the provider about a member’s open quality gaps. The provider can then view the clinical information needed, submit the required documentation, and close the gap.
Looking to do more with Availity Essentials? View our Intelligent Gateway capabilities.
Clinical Gateway + Intelligent Gateway + Essentials capabilities
AutoAuth Create & Exchange
Availity uses ADT information to automatically create the authorization request (x 12 278) and send it to the health plan. Information is then relayed through a bi-directional EMR integration (HL7 with options for exchanging HL7 C-CDA and payer-based health records) to the care provider, often at the time of care.
Looking to do more with Availity Essentials? View Essentials' capabilities.