Availity Revenue Program Management for Health Plans
Risk and Quality

Improve risk and quality data with streamlined provider and health plan communications

As health plans focus on capturing HEDIS measures and managing risk adjustment scores, it’s having a big effect on provider workload. Providers are spending much more time responding to manual requests for clinical data, without additional compensation.

Availity’s risk and quality workflows can minimize phone calls, faxes, and the dreaded chart chase associated with risk and quality initiatives by notifying providers about existing care gaps through the Provider Engagement Portal. Providers can then use simple, online forms to submit just the missing information, rather than faxing over multiple pages of member charts.

Risk Assessment

Providers can use this form, which is pre-populated with member data, to enter assessment and treatment information for patients enrolled in Medicare Advantage, Medicaid, and qualified ACA plans.

Claim Encounter Reconciliation Application (CERA)

Health plans can close care gaps more quickly by querying providers about potential missing documentation shortly after a claim has been submitted. CERA prompts providers to indicate whether a patient with a suspected or previously diagnosed condition was evaluated for that condition during the recent visit. If it was, the provider can use the online form to select from a list of ICD-10 codes and submit the supporting documentation.

Clinical Quality Validation

Providers can submit information required for HEDIS and other health plan quality measures. When providers receive notification about a care gap through the Provider Engagement Portal, this form is pre-populated with both the member and provider information, so providers only need to enter the outstanding information.

Maternity Workflows

When health plans and providers receive early notification of a member’s pregnancy, they are better able to deliver appropriate pre-natal and post-partum care programs. When a provider performs an Eligibility & Benefit inquiry, Availity prompts the provider to indicate if the patient is pregnant. If yes, it generates appropriate requests for additional “notice of pregnancy” information required for HEDIS quality measures.


  • Digital, closed-loop exchange of information between health plans and providers.
  • Email notification to providers of assessment forms, panel rosters, scheduling task lists, and care and coding gaps in the Availity Provider Engagement Portal.
  • Clinical content application allows providers to access HL7 admission, discharge, and transfer data via the inpatient information exchange viewer.
  • Provider education gives providers information about patient quality and risk adjustment processes.


  • Streamlines processes and improves adoption rates by engaging providers within their existing workflows.
  • Improves communication by integrating secure messaging within provider’s EMR workflow.
  • Fosters member care coordination by eliminating time gaps in patient care notification.
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