Problem Statement

After a claim is billed, the payer confirms receipt but staff still have to understand the payment status with the payer. To do this, staff log into each payer portal and look up each claim to see whether it is paid, pending, or denied. Then they write the status and notes back on the account. This is high-volume, repetitive lookup work. The longer an account goes without follow-up, the more likely it ages past 90 days or a timely-filing limit, putting collectible dollars at risk. Capturing statuses quickly also lets accounts receivable be segmented and routed correctly. Denials go to the right work queue, and paid claims close out instead of sitting in the follow-up pile. Pending claims can simply be left to re-check on the next run, sparing staff a portal visit until the claim resolves or stalls (3 runs or 14 business days). For the many payers reachable through Availity, including BCBS, Humana, Aetna, Amerigroup, Molina, and Florida Blue, the bot works the Availity portal per claim, then crosswalks each raw result into an actionable status.

Automation Solution

This automation accesses the Availity portal to retrieve claim statuses for its supported payers. It crosswalks each result into an actionable paid, pending, or denied status and updates the EMR with statuses and routing notes via a CRD and Notes file.