Aviara Health · Eligibility & Claims Validation Agent
Aviara Health · Eligibility & Claims Validation Agent
Aviara Health · Eligibility & Claims Validation Agent
Know if the Visit is covered before you book it.
Know if the Claim will be paid before you send it.
Know if the Visit is covered before you book it.
Know if the Claim will be paid before you send it.
Know if the Visit is covered before you book it.
Know if the Claim will be paid before you send it.
The Eligibility & Claims Validation Agent checks a patient's Insurance while they are still on the phone, and checks every claim against that payer's rules before it leaves your clinic. It is the agent that stops claims from bouncing.
The Eligibility & Claims Validation Agent checks a patient's Insurance while they are still on the phone, and checks every claim against that payer's rules before it leaves your clinic. It is the agent that stops claims from bouncing.
Eligibility Check
on call · 00:41
on call · 00:41
Patient
Patient
M. Alvarez
Plan
Plan
Blue Cross PPO Select
Coverage
Coverage
Active
Network
Network
In network
Referral
Referral
Required, not on file
Deductible remaining
Deductible remaining
$340.00
Front desk
Ask patient for PCP referral before booking. Deductible applies to this visit.
Claim Validation
Aetna · before send
Aetna · before send
99213
99213
Office visit, established patient
Office visit, established patient
Modifier
20610
20610
Joint injection, major
Joint injection, major
Pass
J3301
J3301
Triamcinolone, 10 mg
Triamcinolone, 10 mg
Pass
Suggested fix
Add modifier 25 to 99213. Aetna bundles the visit with the injection without it. Awaiting approval.
Eligibility & Claims Validation
Eligibility & Claims Validation
How it Works
How it Works
How it Works
Two checks, at two moments. Both run on their own.
A person steps in only when something is wrong.
Two checks, at two moments. Both run on their own.
A person steps in only when something is wrong.
Eligibility, on the Call
1
Patient gives payer, plan, and member ID
2
Patient matched to their record
3
Coverage checked with the payer in real time
4
Result read: active, in network, referral or auth needed, deductible left
5
Booking goes ahead, or the front desk is told what to fix
1
Patient gives payer, plan, and member ID
2
Patient matched to their record
3
Coverage checked with the payer in real time
4
Result read: active, in network, referral or auth needed, deductible left
5
Booking goes ahead, or the front desk is told what to fix
1
Patient gives payer, plan, and member ID
2
Patient matched to their record
3
Coverage checked with the payer in real time
4
Result read: active, in network, referral or auth needed, deductible left
5
Booking goes ahead, or the front desk is told what to fix
Claim Validation, before Sending
1
Claim built from the signed note and confirmed codes
2
That payer's rules loaded
3
Every line checked against them
4
Problems flagged, fix suggested, person approves
5
Clean claim sent, tracked until paid
1
Claim built from the signed note and confirmed codes
2
That payer's rules loaded
3
Every line checked against them
4
Problems flagged, fix suggested, person approves
5
Clean claim sent, tracked until paid
1
Claim built from the signed note and confirmed codes
2
That payer's rules loaded
3
Every line checked against them
4
Problems flagged, fix suggested, person approves
5
Clean claim sent, tracked until paid
What it Catches
What it Catches
The problems billing teams see every week, found before they become a denial.
Coverage
Caught on the call, before booking
ON THE CALL
Plan no longer Active
New job, new Medicare, lapsed policy. The card is out of date.
ON THE CALL
Plan no longer Active
New job, new Medicare, lapsed policy. The card is out of date.
ON THE CALL
Out of Network for this plan
You accept the payer, not this plan. The patient would owe the full bill.
ON THE CALL
Out of Network for this plan
You accept the payer, not this plan. The patient would owe the full bill.
ON THE CALL
Referral not on File
HMO specialist visits without a primary care referral are denied outright.
ON THE CALL
Referral not on File
HMO specialist visits without a primary care referral are denied outright.
ON THE CALL
Prior Authorization required
Imaging, procedures, injections this payer will not pay for without an approval number.
ON THE CALL
Prior Authorization required
Imaging, procedures, injections this payer will not pay for without an approval number.
ON THE CALL
Secondary Insurance not recorded
Or primary and secondary swapped, so the claim goes to the wrong payer first.
ON THE CALL
Secondary Insurance not recorded
Or primary and secondary swapped, so the claim goes to the wrong payer first.
ON THE CALL
Deductible not met
The patient owes more than the copay. Say so at booking, not at checkout.
ON THE CALL
Deductible not met
The patient owes more than the copay. Say so at booking, not at checkout.
Claim Rules - United States
Caught before sending, against the payer on the claim
Caught before sending, against the payer on the claim
BEFORE SEND
Missing Modifier
Visit and procedure on the same day without a modifier get bundled and one is denied.
BEFORE SEND
Missing Modifier
Visit and procedure on the same day without a modifier get bundled and one is denied.
BEFORE SEND
Frequency Limit exceeded
Wellness visits, screenings, and some injections are allowed once per window. A second one is rejected.
BEFORE SEND
Frequency Limit exceeded
Wellness visits, screenings, and some injections are allowed once per window. A second one is rejected.
BEFORE SEND
Diagnosis does not support the Procedure
Right service, wrong code pairing, denied for medical necessity.
BEFORE SEND
Diagnosis does not support the Procedure
Right service, wrong code pairing, denied for medical necessity.
BEFORE SEND
Prior Auth number missing from the Claim
The approval exists. It never made it onto the form.
BEFORE SEND
Prior Auth number missing from the Claim
The approval exists. It never made it onto the form.
BEFORE SEND
Provider not yet credentialed with this Payer
A new doctor sees patients before enrolment completes. Rejected for the provider, not the service.
BEFORE SEND
Provider not yet credentialed with this Payer
A new doctor sees patients before enrolment completes. Rejected for the provider, not the service.
BEFORE SEND
Timely filing deadline Close
Payer windows run 90 to 180 days. Ageing claims are flagged before the window shuts.
BEFORE SEND
Timely filing deadline Close
Payer windows run 90 to 180 days. Ageing claims are flagged before the window shuts.
BEFORE SEND
Duplicate Claim
Same service, date, and patient already sent. Resending triggers a rejection and can hold up the original.
BEFORE SEND
Duplicate Claim
Same service, date, and patient already sent. Resending triggers a rejection and can hold up the original.
NPHIES Rules - Saudi Arabia
Caught before sending, against the platform and the policy
Caught before sending, against the platform and the policy
NPHIES
NPHIES
No Eligibility Check on Record
No Eligibility Check on Record
NPHIES expects one before a claim. Without it, the platform rejects the claim before the payer sees it.
NPHIES expects one before a claim. Without it, the platform rejects the claim before the payer sees it.
NPHIES
NPHIES
Pre-Authorization Missing
Pre-Authorization Missing
Many procedures and admissions need approval first. The claim must reference it.
Many procedures and admissions need approval first. The claim must reference it.
NPHIES
NPHIES
Diagnosis & Procedure Codes do not match
Diagnosis & Procedure Codes do not match
ICD-10-AM and SBS codes must be a valid pair for the payer.
ICD-10-AM and SBS codes must be a valid pair for the payer.
NPHIES
NPHIES
Benefits exhausted or excluded
Benefits exhausted or excluded
The plan has a limit or exclusion for this category. The patient should have known before the visit.
The plan has a limit or exclusion for this category. The patient should have known before the visit.
NPHIES
NPHIES
Required Fields missing or malformed
Required Fields missing or malformed
Patient identifiers, encounter class, practitioner details. NPHIES rejects on structure.
Patient identifiers, encounter class, practitioner details. NPHIES rejects on structure.
It works with the other Five Agents
It works with the other Five Agents
It works with the other Five Agents
The Document Agent reads the Insurance Card on a Referral Fax.
Eligibility is checked without asking the patient for anything.
The Document Agent reads the Insurance Card on a Referral Fax.
Eligibility is checked without asking the patient for anything.
The Scribe files the Signed Note.
Codes are suggested from it, the claim is built from the codes. No one re-types anything.
The Scribe files the Signed Note.
Codes are suggested from it, the claim is built from the codes. No one re-types anything.
United States
United States
Availity pVerify
Availity pVerify
Real-time eligibility and claim status across commercial plans, Medicare, and Medicaid.
Real-time eligibility and claim status across commercial plans, Medicare, and Medicaid.
Saudi Arabia
Saudi Arabia
NPHIES
NPHIES
Live. Eligibility, pre-authorization, and claims through NPHIES. 3 hospitals onboarded.
Live. Eligibility, pre-authorization, and claims through NPHIES. 3 hospitals onboarded.
Your EHR
Your EHR
Epic Athena ModMed NextGen CGM DrChrono AdvancedMD eClinicalWorks
Epic Athena ModMed NextGen CGM DrChrono AdvancedMD eClinicalWorks
Every result and decision is written to the patient record.
Every result and decision is written to the patient record.
What it Costs
New contract draft
Implementation from $2,000, one time
Implementation from $2,000, one time
Confirmed after we scope your EHR and payers. Then a monthly subscription billed on what you use: eligibility checks run and claims validated. No per-user fee, no fixed minimum.
Want us to run it? On the Managed option, our team works the exceptions the agent flags and reports the numbers you care about every month.
How Long it Takes
New contract draft
4 Weeks
4 Weeks
On an EHR we already connect to. This covers payer network setup, loading the rules for your top payers, and connecting the result back to your record.
4 to 6 Weeks
4 to 6 Weeks
If we need to build a connector for an EHR we have not worked with. Your EHR needs to have an API.
Identity verification
Patients are verified against the record before any account action, on voice and on chat.
Human in the loop
Transfer logic routes urgent or ambiguous cases to staff. Clinical notes stay editable for physician review.
Average contract cycle time without AI assistance
Traceability
Every agent action is logged. Notes, calls, and referrals link back to the patient record they touched.
Estimated cost per vendor onboarding in legal and admin time
Governance & security
Documented information security, AI governance, data privacy, and incident response policies.
Email threads per vendor before contract execution on average
Questions Billing Teams ask us
Questions Billing Teams ask us
Does it change my claims on its own?
No. It flags the problem and suggests the fix. A person on your team, or on ours if you are on the Managed option, approves it before the claim goes out.
We already have a clearinghouse with claim scrubbing. Why do we need this?
Where do the payer rules come from?
Does it change my claims on its own?
No. It flags the problem and suggests the fix. A person on your team, or on ours if you are on the Managed option, approves it before the claim goes out.
We already have a clearinghouse with claim scrubbing. Why do we need this?
Where do the payer rules come from?
Bring us last month's denials.
We will show you which ones this would have caught.
Ready to Transform
Your Customer
Management?
A 30-minute call with your billing lead. We look at real rejections, not a demo script.
Book a 30-minute call. We’ll walk you through Agreemate, live redlining, and the full drafting workflow with a contract from your own industry.
