Availity and leading health plans to deliver pilot results during HIMSS25 General Education session.

Availity Payer-to-Payer Data Exchange Cohort Pioneers Payer Connections for CMS Interoperability and Prior Authorization Final Rule

Media Contact:
Matt Schlossberg
Director of Public Relations, Availity
630-935-9136
matt.schlossberg@availity.com

Availity®, the nation’s largest real-time health information network, will join two leading health plans to demonstrate insights and best practices gleaned from the company’s Payer-to-Payer Data Exchange Cohort Program at HIMSS25 in Las Vegas.

Pioneering Bidirectional Data Exchange for Mandatory Compliance and Beyond will be presented on Thursday, March 6, 2025, from 12:45 p.m.-1:45 p.m. (PT) at Caesars Academy 415. Availity can also be found on the Exhibit Hall floor at Meeting Place (MP)10017.

Initiated on August 22, 2023, Availity’s dynamic partnership with a select cohort of payers, pioneered the inaugural set of payer connections within the Availity Connectivity Hub. Serving as a one-to-many connection point, the Availity Connectivity Hub is designed to accelerate interoperability and streamline the Payer-to-Payer Application Programming Interface (API) data exchange process, while minimizing reliance on costly, time-consuming point-to-point connections.

The Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F), which goes into effect on January 1, 2027, will require impacted payers to implement and maintain Payer-to-Payer APIs to exchange clinical, claims, and authorization data when a member moves between health plans. Payers will need a robust infrastructure, including data standardization tools, interoperable electronic health record (EHR) systems, and capabilities for secure health information exchange, to meet the requirements as specified in the U.S. Core Data for Interoperability (USCDI) version 1 content standard.

Availity’s Payer-to-Payer Data Exchange Cohort Program aims to address the challenges and hurdles that health plans may encounter when establishing these secure connections with other health plans. By collaborating and testing early, the program aims to identify and address pitfalls and gaps in The Health Level Seven (HL7®) International Da Vinci Payer Data Exchange (PDex) Implementation Guides in advance of 2027—helping payers sidestep implementation challenges and delays to ensure success.

Availity Intelligent Utilization Management

Availity’s Intelligent Utilization Management solution leverages the power of responsible AI to help speed delivery of the right care to patients by reducing friction across all utilization management interventions. The prior authorizations workflow not only streamlines the submission process for providers, but it makes the health plan’s determination process faster, easier, and more transparent.

With Availity’s approach, health plans can establish as single submission pathway for providers, helping ensure compliance with CMS-0057-F. At determination, Availity’s proprietary AI clinical engine evaluates patient records against medical policy to determine medical necessity. More than 70% of the time, this leads to a determination recommendation, getting yesses out of the way for the clinicians. For cases that pend, Availity reduces clinician review time and improves precision by presenting relevant information and questions in decision-tree forms.

In addition to building the infrastructure that enables health plans to transform their utilization management process, Availity is expanding its robust partner ecosystem to ensure clients have access to a variety of best-in-class solutions and content. Availity’s partner network includes industry leaders such as MCG, Salesforce, Concert®, WNS HealthHelp, and Xsolis, among others.

In Other News

Availity announced the launch of Rapid Recovery, an innovative model designed to ensure the rapid restoration of critical healthcare operations following a large-scale catastrophic event. Rapid Recovery leverages cutting-edge technology trusted by U.S. critical infrastructure sectors, including the financial, communication, and defense industries, to deliver a level of resiliency and speed-to-recovery unmatched in healthcare.

About Availity

Availity empowers payers and providers to deliver transformative patient experiences by enabling the seamless exchange of clinical, administrative, and financial information. As the nation's largest real-time health information network, Availity develops intelligent, automated, and interoperable solutions that foster collaboration and shared value across the healthcare ecosystem. With connections to over 95% of payers, more than 3.4 million providers, and over 2,000 trading partners, Availity provides mission-critical connectivity to drive the future of healthcare innovation.

For more information, including an online demonstration, please visit www.availity.com or call 1.800.AVAILITY (282.4548). Follow us on LinkedIn and X.

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