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.

Book a 30-minute Walkthrough

See What it Catches

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

What it Catches

What it Catches

Pricing

Pricing

Book a Call

Book a Call

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.

See all Six Agents

Where the Checks Run

Where the Checks Run

Where the Checks Run

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.

Pricing and Go-Live

Pricing and Go-Live

Pricing and Go-Live

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.

Pricing and the Managed Option

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?

Book a walkthrough

Bring us last month's denials. We will show you which ones this would have caught.

A 30-minute call with your billing lead. We look at real rejections, not a demo script.

Book a 30-minute walkthrough →

Built for HIPAA-regulated workflows · We sign BAAs · SOC 2 Type II in progress

Book a walkthrough

Bring us last month's denials. We will show you which ones this would have caught.

A 30-minute call with your billing lead. We look at real rejections, not a demo script.

Book a 30-minute walkthrough →

Built for HIPAA-regulated workflows · We sign BAAs · SOC 2 Type II in progress

Book a walkthrough

Bring us last month's denials. We will show you which ones this would have caught.

A 30-minute call with your billing lead. We look at real rejections, not a demo script.

Book a 30-minute walkthrough →

Built for HIPAA-regulated workflows · We sign BAAs · SOC 2 Type II in progress

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