Scanning sources…acquiring signal · establishing uplink
2,000+
health plans, government programs, TPAs, workers' comp
2.4M+
physicians, nurses, billers, coders, administrators
13B+
real-time clinical, administrative, and financial transactions
8
from eligibility verification through payment posting
300M+
US individuals whose payers connect through Availity
<2 sec
average real-time eligibility response latency
Platform Architecture
Five interlocking layers of the Availity ecosystemAvaility Essentials (Free)
Core multi-payer portal — free for all providers. Single login replaces dozens of payer-specific portals for administrative transactions.
Real-time eligibility & benefits verification (X12 270/271) across 2,000+ payers
Claim status inquiry (X12 276/277) — batch and real-time
Electronic claim submission — professional (837P) and institutional (837I)
Prior authorization submission, tracking, and status inquiry
Electronic remittance advice (ERA/835) viewing and reconciliation
Patient responsibility estimation — copay, deductible, coinsurance lookup
Referral management and specialist authorization
Provider directory updates and demographic maintenance
Attachment submission (medical records, clinical notes)
Availity Essentials Pro
Premium analytics and workflow automation. Revenue cycle intelligence for enterprise provider organizations and health systems.
Denial analytics dashboard — root cause trending, denial rate by payer/DRG/CPT
Automated eligibility batch verification — schedule daily/weekly runs
Prior auth tracking with deadline alerts and expiration notifications
Claim edit engine — scrub against NCCI, CCI, MUE edits pre-submission
Custom reporting and KPI dashboards — denial rate, clean claim rate, days in AR
Revenue cycle benchmarking against peer organizations
Payer contract modeling and underpayment detection
Automated secondary/tertiary claim routing
API access for EHR/PM/RCM system integration
Payer Spaces
Payer-branded portals hosted within Availity. Each health plan configures custom workflows, forms, communications, and PA criteria within the Availity ecosystem.
Payer-specific prior authorization forms and clinical documentation requirements
Custom utilization management (UM) portals with InterQual/MCG criteria integration
Provider communications — bulletins, policy updates, network alerts
Credentialing status and re-credentialing workflow
Value-based care dashboards (shared savings, quality metrics)
Payer-specific appeals and grievance submission
Pharmacy benefit lookups and formulary searches
Member ID card lookup and plan details
Availity API Platform
RESTful and X12 APIs for programmatic integration. EHRs, RCM platforms, clearinghouses, and health tech companies embed Availity functions into their workflows.
FHIR R4 APIs — CRD, DTR, PAS (Da Vinci IGs) for CMS-0057-F compliance
X12 EDI transaction sets — 270/271, 276/277, 278, 835, 837P/I, 820, 834
Real-time single-patient eligibility API (avg <2 sec response)
Batch eligibility API — up to 5,000 patients per file
Prior authorization submission API (X12 278 + payer-specific extensions)
Webhook/callback notifications for PA status changes and claim adjudication
Provider data management API — NPI, demographics, network status
Attachment API — submit clinical documentation linked to claims/PAs
OAuth 2.0 + API key authentication; HIPAA-compliant transport (TLS 1.2+)
Availity Care Coordination
Clinical data exchange layer for care transitions, referrals, and value-based care programs. Bridges administrative and clinical workflows.
Admission/Discharge/Transfer (ADT) notifications to attributed payers and PCPs
Care gap closure — payer-shared quality measure gaps surfaced in provider workflow
Referral management with specialist availability and network validation
Transition of care alerts for post-acute handoffs (SNF, HH, IRF)
Social determinant of health (SDoH) screening integration
Clinical data attachment for utilization review submissions
X12 / EDI Transaction Matrix
All HIPAA-mandated electronic transaction sets supported through AvailityFHIR R4 / Da Vinci Implementation Guides
CMS-0057-F mandated APIs — Availity as integration middlewarePayer Integration Matrix
National payer connectivity through Availity — function availability per payerUnitedHealthcare / Optum: Largest US payer. Full Payer Space with Optum PA integration. Link portal for medical policy. 2026 admin guide removes PA for select cardiology/radiology. FHIR APIs via Optum developer portal.
Anthem / Elevance Health: Comprehensive Payer Space. InterQual criteria for UM. eviCore specialty PA routing. FHIR Patient Access + Provider Directory APIs in production. MRF files updated monthly.
Aetna (CVS Health): Clinical Policy Bulletins (CPBs) for medical necessity. Expanded electronic PA mandates via Availity. FHIR APIs for CRD/DTR. Precertification list published annually.
Cigna / Evernorth: 29th Edition MCG Care Guidelines (2025-2026). Major procedure at 100%, subsequent at 50%. PA via Availity or CareAllies portal. TiC MRF files up to 1 TB.
Humana: Humana Data Exchange API hub. Transition Period Billing for active treatment continuity. Medicare Advantage coverage documents published annually.
Centene (Ambetter/WellCare): Largest Medicaid managed care org. PA through Centene national portal. TiC files for Ambetter, QualChoice, Health Net, WellCare NC, Fidelis. State-specific Medicaid manuals.
Molina Healthcare: State-by-state TiC/MRF pages. Medicaid PA through state-specific portals within Availity. UM uses InterQual criteria. SNF: up to 100 days with P2P extension.
Kaiser Permanente: Integrated delivery system — limited claims volume from external providers. Provider manuals, Medicare provider directories, EOC docs published. FHIR patient access API.
BCBS Plans (Federation): 36 independent BCBS companies. Each has separate Payer Space and PA workflows in Availity. Federal Employee Program (FEP) claims via Availity. FHIR readiness varies by plan.
CareSource: Major Ohio/multi-state Medicaid MCO. Full Availity integration including custom PA workflows. Ohio's largest Medicaid MCO by enrollment.
Medicare FFS (CMS): Traditional Medicare via MACs (Novitas, NGS, CGS, WPS, Palmetto, etc.). No Payer Space — MAC-specific portals. Blue Button 2.0 FHIR API for beneficiary data. DDE/MCS legacy systems.
Medicaid FFS (State Programs): Varies by state. Most states route eligibility via Availity; PA typically through state MMIS (e.g., Ohio MITS, NY eMedNY, TX TMHP). T-MSIS data feeds to CMS.
TRICARE / VA: Military and veteran health coverage. Eligibility and claims via Availity. PA through TRICARE Health Net Federal Services or regional contractor.
Workers' Compensation: State-specific WC carriers accessible through Availity. First Report of Injury (FROI) and Subsequent Report of Injury (SROI) submissions. PA requirements vary by state.
Revenue Cycle Workflow
10-step end-to-end claims and prior authorization lifecycle through AvailityPatient Scheduling / Pre-Reg
Before service: verify demographic data, capture insurance information, initiate eligibility check. Front-desk or automated batch verification.
Eligibility & Benefits
Real-time 270/271: active coverage, copay, deductible, coinsurance, out-of-pocket max, benefit period, plan type. Batch mode for scheduled patients.
Prior Authorization
Submit PA via X12 278 or Payer Space form. Attach clinical documentation (275). Track status via webhook or polling. CMS-0057 mandates: 72-hr urgent / 7-day standard.
Service Delivery
Clinical care provided. Documentation aligned with PA approval criteria, payer medical policy, and coding requirements. CDI concurrent review.
Charge Capture & Coding
ICD-10, CPT/HCPCS assignment. DRG grouping for inpatient. NCCI/MUE edit validation. Charge reconciliation against orders.
Claim Submission
837P (professional) or 837I (institutional) via Availity. Pre-submission scrubbing against payer-specific edits. Acknowledgment (999/TA1) confirms receipt.
Claim Status Tracking
276/277 real-time inquiry. Adjudication status: pending, in-process, paid, denied. Identify holds, additional info requests, and coordination of benefits issues.
Remittance & Payment
835 ERA received. Payment detail: allowed amount, adjustments, denials, patient responsibility. Reconcile ERA with EFT deposit. Post to PM/billing system.
Denial Management
Denied claims triaged by reason code (CARC/RARC). Root cause analysis. Appeal letter generation. P2P review scheduling. Resubmission or corrected claim filing.
Payment Posting & Reconciliation
ERA/EFT matching. Contractual adjustment validation. Secondary/tertiary billing. Patient statement generation. AR aging analysis.
API Security & Compliance
Authentication, transport, and audit standardsAuthentication
OAuth 2.0 client credentials + API key per registered application
Transport
TLS 1.2+ mandatory; HIPAA-compliant encrypted channels
Identity
SAML 2.0 SSO for portal access; MFA required for administrative functions
Authorization
Role-based access control (RBAC) — admin, biller, coder, clinical, read-only
Audit
Full transaction audit trail; 7-year retention per HIPAA requirements
Compliance
SOC 2 Type II, HITRUST CSF certified, HIPAA BAA with all connected parties
Regulatory & Interoperability Timeline
Federal mandates shaping Availity's roadmap and payer complianceCMS-9115-F: Patient Access API and Provider Directory API required for MA/Medicaid/QHP plans. FHIR R4 mandated.
Interoperability & Prior Authorization final rule. Mandates electronic PA, payer-to-payer data exchange, and FHIR APIs for PA workflows.
MA/Medicaid plans must process urgent PA within 72 hrs, standard within 7 days. Reason codes required with denials. PA status API required.
Availity announces production FHIR R4 API support for CRD, DTR, and PAS workflows — enables payer compliance through Availity as integration layer.
Transparency in Coverage schema standardization effective. Standardized network names and issuer IDs. ~98% reduction in file size. Availity adapts MRF parsing.
All regulated payers must implement FHIR-based CRD, DTR, and PAS APIs. Availity positions as integration middleware bridging FHIR ↔ X12 for payers not yet native.
Automated clinical data exchange between payers for care transitions (PDex). Enables continuity during plan changes, dual-eligible coordination.
Payers must make patient data available to attributed providers via FHIR API with patient consent. Closes the provider data access gap.
Competitive Landscape
Availity positioning vs. major clearinghouse and RCM platformsChange Healthcare (Optum)
Largest US clearinghouse by transaction volume. Suffered massive cyberattack (Feb 2024) — accelerated industry diversification to Availity. Now Optum-owned.
Waystar (formerly Navicure + ZirMed)
Major RCM platform with clearinghouse. Went public 2024. Strong denial management and patient financial engagement.
Trizetto (Cognizant)
Clearinghouse and RCM software. Gateway EDI. Strong in enrollment/eligibility processing for health plans.
Office Ally
Free claims submission platform. Strong with small/independent practices. Limited analytics vs. Availity Pro.
Availity Differentiator
Only platform that is jointly owned by health plans (Anthem, HCSC, Florida Blue). Neutral multi-payer positioning. Free tier creates massive network effect.
Availity - TandemStride
Ohio Medicaid-scoped view — TandemStride trauma reimbursement integration with Availity
Availity Knowledge Base
Entity ID 733618 — healthcare interoperability platform, payer integrations, revenue cycle workflows