Scanning sources…acquiring signal · establishing uplink
2,000+
health plans and government programs
2.4M+
healthcare professionals on the platform
13B+
real-time clinical and administrative transactions
8
from eligibility through payment posting
Platform Architecture
Four interlocking layers of the Availity ecosystemAvaility Essentials (Free)
Core multi-payer portal — free for all providers. Single login to access eligibility, benefits, claims status, and prior authorization across 2,000+ payers.
Real-time eligibility & benefits verification (270/271)
Claim status inquiry (276/277) across all connected payers
Electronic claim submission (837P/837I)
Prior authorization submission and status tracking
Remittance/ERA viewing (835)
Patient responsibility estimation
Availity Essentials Pro
Premium analytics and workflow automation layer. Revenue cycle intelligence, denial management, and predictive analytics for enterprise providers.
Denial analytics dashboard with root cause trending
Automated eligibility batch verification
Prior auth tracking with deadline alerts
Claim edit and scrubbing before submission
Custom reporting and KPI dashboards
API access for EHR/PM system integration
Payer Spaces
Payer-specific portals hosted within Availity. Each health plan configures its own workspace with custom forms, policies, provider communications, and PA workflows.
Molina Healthcare Payer Space — Ohio Medicaid PA forms and UM portal
Anthem / Elevance — commercial and Medicare Advantage workflows
UnitedHealthcare — Optum PA integration
Humana, Cigna, Aetna — payer-specific authorization forms
CareSource — Ohio Medicaid managed care portal
Centene / Buckeye Health Plan — Ohio Medicaid workflows
Availity API & Integration
RESTful and X12 APIs for programmatic access. Enables EHR systems, revenue cycle platforms, and clearinghouses to integrate Availity functions directly into clinical workflows.
FHIR R4 APIs (preparing for CMS-0057-F mandate)
X12 270/271, 276/277, 278, 837 transaction sets
Real-time API for eligibility (avg response <2 sec)
Bulk/batch submission APIs for high-volume providers
Webhook notifications for PA status changes
HL7 integration for clinical data exchange
Payer Integration Matrix
Ohio-relevant payers accessible through Availity — function availability per payerMolina Healthcare of Ohio: Full Payer Space integration; custom PA forms for trauma, DME, SNF transitions. TandemGuides referral pathway accessible via Molina portal.
Ohio Medicaid (FFS): Eligibility and claims via Availity; PA managed through Ohio MITS portal (not Availity). Remittance available.
CareSource: Full integration including custom PA workflows. Ohio's largest Medicaid MCO by enrollment.
Anthem / Elevance: Comprehensive Payer Space. InterQual criteria accessible through PA workflow. eviCore specialty PA routing.
UnitedHealthcare / Optum: Optum PA integration. Link portal for medical policy lookups. High volume of trauma-related PA for commercial members.
Buckeye Health Plan (Centene): Claims and eligibility via Availity. PA through Centene's national portal with Ohio-specific rules.
Revenue Cycle Workflow
8-step claims and prior authorization lifecycle through AvailityEligibility Verification
Real-time 270/271 check — confirms active coverage, copay, deductible, and benefit limits before service
Prior Authorization
Submit PA request through Payer Space (Molina, Anthem) or X12 278 transaction. Track status in real-time
Service Delivered
Clinical care provided — trauma surgery, rehab, DME fitting. Documentation aligned with PA approval criteria
Claim Submission
837I (institutional) or 837P (professional) submitted through Availity. Scrubbed for NCCI edits pre-submission
Claim Status Check
276/277 real-time inquiry. Track adjudication status, identify holds, and detect pending issues early
Remittance / ERA
835 electronic remittance advice received. Payment posted, denials flagged for appeal pipeline
Denial Management
Denied claims routed to appeal workflow. Root cause coded, appeal letter generated, P2P scheduled if needed
Payment Posting
Reconcile ERA with expected payment. Flag underpayments, contractual adjustments, and patient balance
TandemStride Integration Points
How Availity connects to the trauma reimbursement workflowEligibility verification via Availity confirms Molina/Ohio Medicaid coverage before trauma activation billing begins
Submit concurrent review updates to Molina through Availity Payer Space — prevents gap denials during acute trauma stays
DME and SNF prior authorizations submitted through Availity. TandemGuides navigator coordinates timing with PA approval status
SNF and outpatient rehab claims tracked through Availity claim status. Early denial detection enables same-day appeal initiation
Denied trauma claims identified through ERA/835 in Availity. Appeal pipeline fed with denial reason codes and clinical documentation
Regulatory & Interoperability Timeline
CMS mandates shaping Availity's roadmapInteroperability & Prior Authorization final rule — mandates electronic PA, payer-to-payer data exchange, and FHIR APIs
MA/Medicaid plans must process urgent PA within 72 hrs, standard within 7 days. FHIR-based PA APIs required
Availity announces FHIR R4 API support for CRD, DTR, and PAS workflows — enables CMS-0057 compliance
Transparency in Coverage schema standardization — Availity adapts network file parsing for downstream consumers
All regulated payers must implement FHIR-based prior authorization APIs (CRD, DTR, PAS). Availity positions as integration layer
Automated clinical data exchange between payers for care transitions — Availity FHIR infrastructure enables multi-payer coordination
Availity Knowledge Base
Entity ID 733618 — healthcare interoperability platform, payer integrations, revenue cycle workflows