Aviara Health · RCM Agent
Your Billing Queue, worked for you.
Your Billing Queue, worked for you.
The RCM Agent prepares prior authorizations, sends claims, and chases the ones that come back. Nothing leaves until a person says yes.
The RCM Agent prepares prior authorizations, sends claims, and chases the ones that come back. Nothing leaves until a person says yes.
A Tuesday in the queue
Illustrative
Prepared by the agent
3
Prior auth, MRI knee
M. Alvarez, BCBS. Notes attached from visit.
Ready
Claim 4482
Office visit and injection. Validated, modifier 25 added.
Ready
Claim 4471, corrected
Denied for missing auth. Auth found, added.
Ready
Waiting for your approval
3
Prior auth, MRI knee
M. Alvarez, BCBS. Notes attached from visit.
Approve and Submit
Claim 4482
Send via clearinghouse
Approve and Submit
Claim 4471, corrected
Resend to Aetna. 61 days left to file.
Approve and Submit
Sent, being tracked
9
Prior auth, epidural
UHC. Submitted Mon. Checking daily.
Pending Payer
Claim 4482
Accepted by payer. Payment expected in 14 days.
Accepted
Claim 4460
Appeal filed with visit note. Awaiting review.
Appeal Open
Resolved this week
13
Claim 4451
Paid in full.
Paid
Prior auth, CT abdomen
Approved. Number saved to chart.
Accepted
Claim 4439
Paid after COB correction.
Paid
Prepared by the agent
3
Prior auth, MRI knee
M. Alvarez, BCBS. Notes attached from visit.
Ready
Claim 4482
Office visit and injection. Validated, modifier 25 added.
Ready
Claim 4471, corrected
Denied for missing auth. Auth found, added.
Ready
Waiting for your approval
3
Prior auth, MRI knee
M. Alvarez, BCBS. Notes attached from visit.
Approve and Submit
Claim 4482
Send via clearinghouse
Approve and Submit
Claim 4471, corrected
Resend to Aetna. 61 days left to file.
Approve and Submit
Sent, being tracked
9
Prior auth, epidural
UHC. Submitted Mon. Checking daily.
Pending Payer
Claim 4482
Accepted by payer. Payment expected in 14 days.
Accepted
Claim 4460
Appeal filed with visit note. Awaiting review.
Appeal Open
Resolved this week
13
Claim 4451
Paid in full.
Paid
Prior auth, CT abdomen
Approved. Number saved to chart.
Accepted
Claim 4439
Paid after COB correction.
Paid
RCM Agent
Eligibility and claims validation
Three Jobs.
One Rule: A Person Approves every Step.
Three Jobs.
One Rule: A Person Approves every Step.
Three Jobs.
One Rule: A Person Approves every Step.
The Agent does the preparing and the waiting. Your team does the approving. That is the whole design.
The Agent does the preparing and the waiting. Your team does the approving. That is the whole design.
Prior Authorization
Service ordered in the visit note
Payer's auth rules checked
Request built from the note and codes
Approve and submit
Person
Sent to the payer portal, or NPHIES
Decision tracked, auth number saved to the chart
Claim Submission
Claim built from confirmed codes
Checked against the payer's rules
Approve and send
Person
Sent via your clearinghouse, or NPHIES
Tracked until paid
Denials
Denial received, reason read
Cause found in the chart, auth, or claim
Correction or appeal drafted
Approve and resend
Person
Tracked until resolved
Prior authorization
Service ordered in the visit note
Payer's auth rules checked
Request built from the note and codes
Approve and submit
Person
Sent to the payer portal, or NPHIES
Decision tracked, auth number saved to the chart
Claim submission
Claim built from confirmed codes
Checked against the payer's rules
Approve and send
Person
Sent via your clearinghouse, or NPHIES
Tracked until paid
Denials
Denial received, reason read
Cause found in the chart, auth, or claim
Correction or appeal drafted
Approve and resend
Person
Tracked until resolved
What Lands in the Queue, and
What the Agent does with it
What Lands in the Queue, and
What the Agent does with it
Real situations billing teams deal with every week, shown as the agent presents them.
Denials
when a claim comes back
Prior auth missing
CO-197
Auth was obtained, never put on the claim
The approval sits in the chart. The claim went out without the number.
Agent's fix Auth number added, corrected claim prepared.
61 days left to file
Approve and resend
Prior auth missing
CO-197
Auth was obtained, never put on the claim
The approval sits in the chart. The claim went out without the number.
Agent's fix Auth number added, corrected claim prepared.
61 days left to file
Approve and resend
Coverage
CO-27
Coverage ended before the date of service
Patient changed plans. The old card was still on file.
Agent's fix New plan found in eligibility history. Claim rerouted.
Patient notified
Approve and resend
Coverage
CO-27
Coverage ended before the date of service
Patient changed plans. The old card was still on file.
Agent's fix New plan found in eligibility history. Claim rerouted.
Patient notified
Approve and resend
Other payer primary
CO-22
Coordination of benefits
Payer says another plan should pay first.
Agent's fix Primary and secondary swapped. Claim rebuilt.
Both plans on file
Approve and resend
Other payer primary
CO-22
Coordination of benefits
Payer says another plan should pay first.
Agent's fix Primary and secondary swapped. Claim rebuilt.
Both plans on file
Approve and resend
Medical necessity
CO-22
Payer disputes the need for the service
Diagnosis on the claim does not meet the payer's policy.
Agent's fix Appeal drafted from the visit note and the payer's own policy.
Needs clinician review
Review appeal
Medical necessity
CO-22
Payer disputes the need for the service
Diagnosis on the claim does not meet the payer's policy.
Agent's fix Appeal drafted from the visit note and the payer's own policy.
Needs clinician review
Review appeal
Information needed
CO-16
Missing attachment
Payer wants the operative note before paying.
Agent's fix Note pulled from the chart, attached to the resend.
Attachment ready
Approve and resend
Information needed
CO-16
Missing attachment
Payer wants the operative note before paying.
Agent's fix Note pulled from the chart, attached to the resend.
Attachment ready
Approve and resend
Timely filing
CO-29
Filed after the payer's deadline
Original was sent in time, but the payer has no record.
Agent's fix Proof of original submission found. Timely filing appeal drafted.
Proof attached
Approve appeal
Timely filing
CO-29
Filed after the payer's deadline
Original was sent in time, but the payer has no record.
Agent's fix Proof of original submission found. Timely filing appeal drafted.
Proof attached
Approve appeal
Prior Authorizations
before the service
Auth needed
MRI
Imaging ordered in the visit note
This payer requires approval for advanced imaging.
Agent's action Request built from the note. Diagnosis, service, reasoning attached.
Ready in minutes
Approve and submit
Auth needed
MRI
Imaging ordered in the visit note
This payer requires approval for advanced imaging.
Agent's action Request built from the note. Diagnosis, service, reasoning attached.
Ready in minutes
Approve and submit
Pending
Day 4
Payer has not responded
Request submitted, no decision yet.
Agent's action Portal checked daily. You are told the moment it moves.
No action needed
Tracking
Pending
Day 4
Payer has not responded
Request submitted, no decision yet.
Agent's action Portal checked daily. You are told the moment it moves.
No action needed
Tracking
Approved
CO-22
Approval received
Auth number issued by the payer.
Agent's action Number saved to the chart and carried onto the claim, so this never becomes a CO-197.
Done
Saved
Approved
CO-22
Approval received
Auth number issued by the payer.
Agent's action Number saved to the chart and carried onto the claim, so this never becomes a CO-197.
Done
Saved
What Feeds it, and What it Sends on
What Feeds it, and What it Sends on
What Feeds it, and What it Sends on
AI Scribe
AI Scribe
Files the signed visit note. The prior auth request and the claim are built from it, not from a form.
AI Scribe
Eligibility & Claims Validation
Eligibility & Claims Validation
Checks coverage at booking and the claim before sending. The RCM agent only sends what has passed.
RCM Agent
RCM Agent
Submits, tracks, and works what comes back. Auth numbers and outcomes written to the patient record.
AI Scribe
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
US Payer Portals
US Payer Portals
For prior auth and claim status, the agent signs in with your clinic's login and fills the form the way your staff would. Any payer with a portal.
For prior auth and claim status, the agent signs in with your clinic's login and fills the form the way your staff would. Any payer with a portal.
US Clearing Houses
US Clearing Houses
Claims go through the clearinghouse you already use.
Claims go through the clearinghouse you already use.
Availity
Availity
Saudi Arabia
Saudi Arabia
Prior authorization and claims direct through the national platform. Live, 3 hospitals onboarded.
Prior authorization and claims direct through the national platform. Live, 3 hospitals onboarded.
NPHIES
NPHIES
Your EHR
Your EHR
Auth numbers, claim status, and denial outcomes written back to the patient record.
Auth numbers, claim status, and denial outcomes written back to the patient record.
NPHIES
NPHIES
Athena
Athena
ModMed
ModMed
NextGen
NextGen
CGM
CGM
DrChrono
DrChrono
AdvancedMD
AdvancedMD
eClinicalWorks
eClinicalWorks
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
Starts at $2,000
New contract draft
one-time Implementation, confirmed after Scoping
Then a monthly subscription billed on what you use: prior auths submitted, claims sent, denials worked. No per-user fee, no fixed minimum.
Want us to do the approving too? On the Managed option our team runs the queue to rules you set, and reports the numbers you care about every month.
4 weeks
New contract draft
to go live on an EHR we already connect to
Week 1
Payer portal access, clearinghouse setup, your approval rules
Week 2
Connected to your EHR, first prior auths prepared for review
Week 3
Claims and denials flowing into the queue, your team approving
Week 4
Live. Weekly check-ins for the first month
New EHR we have not connected before: 4 to 6 weeks. It needs 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
What Billing Teams ask
What Billing Teams ask
Does it submit anything without us?
No. Every prior auth, claim, resend, and appeal is prepared by the agent and approved by a person before it goes. On Managed, that person is on our team, working to rules you set.
How does it get into payer portals?
We have a billing company. Does this replace them?
Does it submit anything without us?
No. Every prior auth, claim, resend, and appeal is prepared by the agent and approved by a person before it goes. On Managed, that person is on our team, working to rules you set.
How does it get into payer portals?
We have a billing company. Does this replace them?
Show us your Denial Queue.
Ready to Transform
Your Customer
Management?
Thirty minutes with your billing lead. We work through real claims and tell you which ones never had to come back.
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.
