Robust functionality helps improve collaboration
Provider portals are vital for health plans to communicate with providers, helping reduce calls and emails into their support teams. They are also critical to providers because they allow them to run an eligibility and benefits check, view a claim’s status and take appropriate action based on that status, all without picking up the phone and calling the plan. But with increased regulations and ever-present security threats, it’s difficult for health plans to dedicate the budget and resources necessary to maintain these systems in-house.
Availity’s nationwide, multi-payer Provider Engagement Portal helps providers and health plans collaborate and share information easily and efficiently. Providers benefit by having one place to go to accomplish key tasks for multiple plans, and health plans benefit as providers opt for self-service rather than contacting their call centers. Strengthen your relationship with providers through enhanced data and capabilities from the Intelligent Gateway and Clinical Gateway.
Provider Engagement Portal Capabilities
The Patient Management Solution is a configurable workflow in which providers can access detailed patient eligibility and benefit information, as well as other pre-service information relevant to the encounter. The Patient Management workflow is the starting point for other Portal workflows, and information generated here is carried over to those workflows, reducing data entry for the provider.
Providers use our Claims Management Solution to research and address issues related to a claim. After checking a claim’s status, providers can follow a series of other workflows, including responding to a plan’s overpayment request, initiating an appeal, sending attachments, and messaging the health plan. And, of course, they can also submit a claim, correct a previously submitted claim, and generate a cost estimate for a member encounter.
With our Financial Management Solution, providers can access detailed ERA information and take payment actions. From our dashboard, providers can easily view their claim payments, exceptions, reversals, and reduced payments across multiple payers. Providers can also process payments here, which includes collecting co-pays and deductibles, and setting up patient payment plans.
Provider Information Management
Health plans use annual contracting and credentialing processes to update provider information records, which means that their provider data is only accurate for one day a year. Relying on these methods leads to out-of-date directories and an inaccurate view of the provider network. Availity’s Provider Information Management Solution features several workflows designed to address the challenge of maintaining up-to-date provider information. Using the Portal, providers can verify key demographic information. After providers attest to data accuracy, Availity sends the updates in real-time or batch to all plans with whom the providers work. Availity ensures each plan receives the data in a format that can be integrated into that plan’s back-end systems.
Our Provider Engagement Solution gives health plans multiple channels through which to communicate and share information with providers: two-way messaging, home page notifications, news and announcements, and promotions. Health plans use these tools to tell a provider when a medical record is required, to submit an overpayment request or respond to an appeal, to keep an exact record of communication with the provider, (one that’s not subject to a representative’s interpretation or note-taking skills), and for countless other reasons. In addition, the Provider Engagement Solution delivers feedback functionality, giving health plans better insight into what their providers need and want from the plan and the Portal applications.
Authorization and Referral Management
Determining if a prior authorization is required is one of healthcare’s most time-consuming and frustrating processes, and it’s a big source of administrative cost for health plans and providers alike. The Authorization and Referral Management Solution allows providers to manage all aspects of the prior authorization process electronically. Here, providers determine if an authorization is required, enter and submit the prior authorization request, attach medical records (Clinical Gateway required), and view the status of a request.
While the Availity Portal is a multi-payer environment, individual health plans still must make proprietary content, such as medical policies and quality reporting, available to providers. Payer Spaces addresses this need by allowing health plans to host plan-specific information from within the Portal via a health plan-branded page. Payer Spaces is both a repository and a platform with its own set of development tools, so health plans can develop (on their own or with Availity’s support) robust applications, allowing them to securely share information with their providers.
Health plans need reliable data about how their provider network is performing to make good decisions. Availity 360 uses administrative data, transactional data and other Portal activity to deliver a clear picture of the network’s health. With Availity 360, health plans can better identify trends and drill down into performance metrics based on payer, transaction type, and more.
Provider Engagement Portal + 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 our Provider Engagement Portal 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 the Portal, and sends clinical messages through the Portal’s 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 the Portal 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.
Clinical Gateway + Intelligent Gateway + Provider Engagement Portal 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.