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Clinical Data Solutions for Health Plans

Acquire, optimize, and activate clinical data to address administrative challenges and improve care outcomes through enhanced data exchange and interoperability

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Payers have long struggled to gain visibility into their member populations, in large part because of the healthcare industry’s long-time orientation around fee-based reimbursement models. After a patient visit, data from that encounter spits into two different paths: coding and payment information flows to claim adjudication systems, while lab results, provider notes, and testing results reside in EHRs and other clinical systems. Much of the waste and abrasion the industry faces today is caused by payers and vendors trying to bring this information back together to get the full picture of the clinical encounter. A barrier to seamless healthcare exchange and true interoperability.

Availity helps payers reintegrate clinical and administrative data for use across the enterprise with a set of solutions designed to improve connectivity, standardization, and readiness for evolving regulatory requirements.     

Clinical Data Acquisition

Clinical Data Optimization

Clinical Data Activation

Clinical Data Acquisition

Enhance and simplify clinical data connectivity  

Clinical data exists across the healthcare ecosystem—in EHRs, HIEs, state registries, data aggregators, record retrieval vendors, and other payer organizations. Without a single, easy way to connect to each data source, payers have struggled to get timely access to critical data.        

As a long-time trusted intermediary for healthcare administrative transactions, Availity is uniquely positioned to simplify clinical connectivity. Our extensive network of trading partners and deep technical expertise means we can address payer-specific connectivity requirements based on state, region, lines of business, EHR vendors, and compliance standards such as those set by CMS.   

Connectivity Options  

Direct Clinical Connections
Reduce the technical and operational challenges of managing connectivity for payers with existing provider and vendor connections.

Clinical Trading Partner Network
Leverage Availity’s extensive relationships with HIT vendors nationwide to quickly support RESTful API integration and modern data standards.

Availity Administrative Network
Access rich, clinical data that’s transmitted via administrative transactions, including claims and authorizations.

Payer-to-Payer Connections
Become part of Availity’s industry-leading connectivity hub that helps accelerate  interoperability mandate compliance (CMS-0057)

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Clinical Data Optimization

Improve the quality and usability of clinical data

For some payers, the challenge isn’t how to access more clinical data; it’s how to make sense of the data they already have efficiently and at scale. Data acquired from multiple, disparate sources must be evaluated, standardized, and normalized before it can be effectively deployed into clinical and administrative workflows. But these manual, time-consuming processes take analytics and informatics staff away from higher-value activities.

Availity helps payers better scale their clinical operations by ingesting data from multiple sources and formats (C-CDA, FHIR, PDF, and more) and transforming it into a robust asset that can be used across the enterprise.    

Data Quality Optimization

Parse
data into discrete clinical entries to support an organizational structure  

Normalize
data to industry standard technologies by creating a common language for data exchange to achieve semantic interoperability.

Enrich
data with standard metadata and classifications to ensure efficient analytics queries and optimize data for most effective downstream use.

Reorganize
data to appropriate clinical document sections by creating a complete, updated view of patient history for appropriate outreach and care delivery.

Deduplicate
incoming data systems to ensure clean inputs for value-based care, claims accuracy, and longitudinal insights

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Clinical Data Activation

Infuse fit-for-purpose clinical data into administrative and clinical workflows

Once clinical data has been acquired and transformed, it’s ready for use in multiple workflows across the enterprise. For many payers, this has been the missing piece. How to put the clinical data they already have to use throughout the enterprise.     

On the clinical side this includes improving HEDIS® and Stars ratings, supporting value-based care programs, optimizing utilization management initiatives, and more. Clinical data can also be used to optimize administrative workflows such as claims editing, claims attachments.

Availity partners with payers and providers to assess how best to deploy data into workflows.  The following are some of relevant use cases.

Enterprise Use Case Enablement

Clinical Quality Validation
Provider portal application that addresses open quality care gaps.

Risk Condition Validation
Provider portal application that addresses open risk care gaps.

EHR Gap Integration
Risk and quality care gap information in integrated into EHRs.

Care Gap Claim Editing
Upfront claim editing that identifies potential care gaps prior to claim submission  

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Learn more about how Availity can help

Solution

Interoperability

Transform data-sharing capabilities and reduce the cost of care.

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Solution

End-to-End Authorizations

Learn how Availity eases prior authorization burdens with AI-driven solutions to help reduce costs and improve care.

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Case Study

Why Upcycling Data™ Matters

Learn how Availity can help you harness the power of bi-directional data intelligence to reduce costs, improve care quality, and drive innovation.

Read the study

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