One focus area is simplifying prior authorization by aligning order submission and utilization management processes with the clinical encounter, with the goal of enabling payer determinations during the visit. Intelligent workflowsLeverage Availity’s AI-enabled platform to automate and transform complex payer/provider workflows Dual-sided innovationReduce friction and drive behavior change with solutions that deliver shared value for payers and providers From providers to payers to HITs, industry leaders trust Availity to power mission-critical connectivity and innovation. We’re excited to collaborate with Abridge and to demonstrate what’s possible when payer intelligence meets real-time provider workflows.”
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- We’re excited to collaborate with Abridge and to demonstrate what’s possible when payer intelligence meets real-time provider workflows.”
- Reduce time spend waiting for authorization approval.
- The collaboration ensures a shared clinical context at the point of conversation for prior authorization review and submission, the companies said.
- The Availity portal eases common tasks and transactions so you can focus on patient care.
Abridge’s Contextual Reasoning Engine is used to surface relevant clinical information during the encounter, allowing clinicians to address documentation needs as part of the conversation, rather than through separate, post-visit processes. The platform is currently used by more than 200 health systems. Connected admin and clinical data for better decision-making Delivering innovative solutions for complex payer/provider engagement & workflow automation • Accelerated digital adoption• Right data, right time• Improved precision and reduced waste• Deeper network insights
For costs and complete details of the coverage, please contact your agent or the health plan. Use Availity.com to check claim status, dispute claims, maintain provider data and so much more! Please use the Availity Essentials provider website for inquiries like payment disputes, provider data updates, claims status, member eligibility. Microsoft’s Nuance also offers a clinical documentation tool, Dragon Ambient eXperience (DAX) Copilot, formerly DAX Express, which uses OpenAI’s model GPT-4.
Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Treating providers are solely responsible for medical advice and treatment of members. The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. Aetna Inc. and its affiliated companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.
Providers, payers & HITs look to Availity for…
As the nation’s largest dual-sided, real-time healthcare network, Availity brings unparalleled scale & reach • All-payer and all-provider reach• Extensible platform capabilities• Developer-first experience• Flexible APIs• Accelerated speed to value “At Availity, we’ve invested in building AI-powered, FHIR-native APIs designed to bring clinical policy logic directly into provider workflows,” said Russ Thomas, CEO of Availity. Technology in the clinician-patient conversation facilitates a more efficient process between clinicians and health plans in medical necessity review, the companies said.
Patients & mental health
“Abridge and Availity are each bringing national scale, deep trust, and a track record of solving important challenges across the care and claims experience to this partnership,” said Dr. Shiv Rao, CEO and cofounder of Abridge. “By embedding our technology at the point of conversation, we’re enabling faster, more transparent utilization management decisions rooted in clinical context. Abridge, which serves more than 200 health systems, is projected to support over 80 million patient-clinician conversations in 2026. Real-time conversational intelligence identifies gaps during a visit. To get specific info about your plan’s definition of a term, or for coverage details, check your plan documents.
The approach is designed to reduce administrative delays by aligning clinical documentation with payer requirements in real time. Abridge and Availity are partnering to develop a real-time prior authorization experience integrating utilization management directly into the clinician/patient conversation to streamline interactions between providers and health plans. Network reachConnect with payers, providers and HITs nationwide through Availity’s real-time health information network The goal is to help both payers and providers reduce manual workflows, administrative delays and peer-to-peer consults. Abridge has teamed its AI platform for clinical conversations with Availity’s digital platform that connects payers and providers to enable payer determination during a patient visit.
- Other companies in the AI medical documentation space include Commure, which in June 2025 raised $200 million in growth funding from General Catalyst’s Customer Value Fund.
- Abridge, which serves more than 200 health systems, is projected to support over 80 million patient-clinician conversations in 2026.
- MapsofIndia has updated its Terms and Privacy Policy to give Users more transparency into the data this Website collects, how it is processed and the controls Users have on their personal data.
- Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).
- From providers to payers to HITs, industry leaders trust Availity to power mission-critical connectivity and innovation.
Solutions
Search for and review Highmark medical policies and get the latest updates. Browse our archive of previous newsletters, provider updates, and Special Bulletins. Stay informed of the latest medical policy changes and updates.
Availity operates a health information network connecting payers and providers, offering tools that digitize coverage requirements and support administrative workflows across the healthcare ecosystem. Availity’s FHIR-native Intelligent Utilization Management platform helps payers and providers digitize and operationalize coverage requirements within administrative workflows. The collaboration reflects a broader trend in health IT toward embedding administrative and revenue cycle functions into clinical workflows, using real-time data exchange and AI-driven context to support compliance and operational efficiency.
Other companies in the AI medical documentation space include Commure, which in June 2025 raised $200 million in growth funding from General Catalyst’s Customer Value Fund. Seattle Children’s Hospital already implements Abridge’s AI platform enterprise-wide to convert medical conversations into billable pediatric documentation, and Connecticut’s Hartford HealthCare expanded use of Abridge’s platform in September of last year after a successful pilot program. Real-time prior authorization is just one component of a broader effort to apply conversational intelligence across the revenue cycle. The collaboration relies on Availity’s FHIR-native APIs to enable secure, scalable exchange of payer data, including coverage rules and utilization management requirements. Abridge provides AI technology that captures and structures clinical conversations, generating documentation aligned with clinical and administrative needs.
Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. Applications are available at the American Medical Association Web site, -assn.org/go/cpt. In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. The member’s benefit plan determines coverage. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member.
By supporting prior authorization documentation and submission during the visit, the approach is intended to reduce manual workflows, administrative delays and resource-intensive processes such as peer-to-peer consultations. The companies are working to align workflows across their platforms in several areas, including utilization management, documentation and authorization review. Unified admin & clinical dataImprove care & financial outcomes by integrating administrative and clinical data into key workflows “We’re building real-time bridges between patients, providers, and payers, unlocking shared understanding, focused at the point of conversation.”
You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. Members and their providers will need to consult the member’s benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Members should discuss any matters related to their coverage or condition with their treating provider. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). Availity is the place where healthcare finds the answers needed to shift focus back to patient care.
Aetna Inc. and its affiliates are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites. This information is neither an offer of coverage nor medical advice. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services.
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Aetna Inc. and its affiliated companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. Aetna Inc. and its affiliated companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites. Aetna Inc. and its affiliated companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites. The company’s suite of dynamic products, built on a powerful, intelligent platform, enables real-time collaboration for success in a competitive, value-based care environment. As the nation’s largest health information network, Availity facilitates over 13 billion clinical, administrative, and financial transactions annually. Is prior authorization needed?
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Health benefits and health insurance plans contain exclusions and limitations. The Availity portal eases common tasks and transactions so you can focus on patient care. The Availity provider portal is your one-stop shop for doing business with us. Find out how one health system reduced denials and accelerated reimbursement with Essentials Pro Attachments.
The information is being shared between providers and payers, as opposed to having parallel AI systems. The collaboration ensures a shared clinical context at the point of conversation for prior authorization review and submission, the companies said. By solving the communication challenges between healthcare stakeholders, Availity creates a richer, more transparent exchange of information among health plans, providers, and technology partners.
The development of real-time prior authorization is one component of revenue cycle collaboration using conversational intelligence, the companies said. Its Contextual Reasoning Engine technology gives visibility into clinical information during the conversation to support documentation aligned with prior authorization requirements. Availity is used by 95% of payers and supports 3.5 million providers.
