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Want to reduce claims calls? There’s an API for that

Did you know that claim status inquiry is one of the few healthcare transactions that experienced a drop in electronic adoption during the pandemic? That’s according to the 2021 CAQH Index Report, which also found the cost to conduct a manual transaction increased significantly for both health plans and providers. The drop in adoption and the cost increase were largely attributed to changes in telemedicine requirements.

As the product line director for claims management at Availity, I wasn’t surprised by this finding. The claim status inquiry transaction has long been a source of abrasion for health plans and providers; the pandemic just exacerbated it. Providers don’t want to spend 25 minutes on the phone (the average time, according to CAQH) to follow up on a claim’s status, and health plans don’t want to expend time and resources to supplement the lack of information in the original transaction. 

Fortunately, Availity has been working closely with health plans in our network on a solution. The result is our Enhanced Claim Status RESTful API, which is available through Availity EssentialsEssentials Pro, and now through our EDI Clearinghouse.

RESTful APIs have steadily grown in popularity because they support the exchange of rich, value-added content. They help ensure that protected health information communicated between health plans and providers remains seamless and reliable across all channels, while maintaining high levels of security, accountability, and user authentication.

Here’s how RESTful API is making a difference with claim status:

Richer claim status detail reduces phone calls

Even before the pandemic, claim status inquiry had lower electronic adoption compared to other administrative transactions. The reason is that the X12 276/277 transaction is limited in the amount of information it can return to a provider. When providers receive the response, the information often isn’t clear or doesn’t offer enough detail, so providers have no choice but to call the health plan for more information.

With Availity’s Enhanced Claim Status RESTful API, health plans can customize the X12 277 response with up to 300 additional information fields, including remark codes and descriptions, amount fields (deductible, discount, copay, co-insurance, patient responsibility), group number, line of business, provider type (rendering, billing), and many more.

Omnichannel approach delivers consistent information for all providers

Availity is committed to an omnichannel content approach, which means providers (and other submitters) can access the same rich health plan information available within Essentials through Essentials Pro or other vendors via our trading partner network. Leveraging REST APIs like Enhanced Claim Status allows us to do that. 

Availity developed Enhanced Claim Status as a multi-payer API to drive standardization across health plans and to simplify the integration process for our trading partners. We also focused on flexibility to allow health plans to customize the fields they populate based on the information they have available. However, the ultimate goal is for health plans to deliver the same robust data, so providers have a consistent experience.

Learn more

Today, more than a dozen Availity health plans leverage Enhanced Claim Status to improve their providers’ experience, and more are coming soon. To learn more, visit Enhanced Claim Status.