Availity API

Overview

Availity is the largest healthcare information network in the United States, connecting providers and payers for eligibility verification, claims submission, prior authorization, and remittance. The network spans the major commercial payers, Blue Cross Blue Shield plans, Medicare Advantage plans, and Medicaid programs across every state. For a healthtech company building patient access tools, RCM automation, or prior authorization products that target provider organizations, Availity is a required integration: a substantial share of provider-payer transactions in the US move through the Availity network.

The access barrier is structural rather than technical. Availity's API access for workflow data requires provider enrollment in the Availity network and payer-specific agreements for each payer a provider wants to transact with electronically. This enrollment model was designed for provider organizations, not for software companies building products on top of Availity's data layer. A development team cannot create a developer account, provision sandbox credentials, and start building. The team must complete provider enrollment, establish individual payer relationships, and satisfy Availity's trading partner requirements before a single API call is possible. The timeline and complexity scale with the number of payers the product needs to support.

Integuru generates a production-ready HTTP API for Availity using direct HTTP requests against the same endpoints Availity's web portal uses internally. Eligibility inquiries, claims submission, prior authorization tracking, remittance retrieval, and patient balance data are all reachable through Integuru's API without a provider enrollment dependency. The Production plan's 24/7 on-call maintenance team handles session management, re-authentication, and endpoint changes before they affect your production calls. Integuru can be deployed in HIPAA-compliant environments; discuss your compliance requirements when you chat with us.

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Why Teams Need This Integration

Availity's position as the primary provider-payer transaction network means that building on its data is not optional for most patient access and RCM products. The enrollment structure means it is also not a quick start.

Eligibility verification platforms and patient access tools. Real-time eligibility is the foundational check that determines whether a patient is covered, what their cost-sharing obligations are, and whether a service requires prior authorization before it can be rendered. check_eligibility and get_eligibility_response surface this data as direct API calls, returning coverage details, deductible balances, copay amounts, and in-network status without a batch eligibility file workflow. For a patient access platform that serves practices across payers on the Availity network, real-time eligibility is the core data requirement.

Claims submission and status tracking. Billing automation tools and RCM platforms that support practices transacting through Availity need programmatic claims submission and status retrieval across the full claims lifecycle. submit_claim, get_claim_status, and list_claims give billing platforms a live API layer for claims management without requiring staff to log into the Availity portal to check submission status or resolve rejections manually.

Prior authorization automation. PA automation is one of the highest-friction areas in the provider-payer workflow. submit_prior_auth and get_prior_auth_status expose the Availity PA portal as API calls, giving utilization review tools, AI prior authorization platforms, and care management systems programmatic access to authorization submission and status tracking across the payers on the Availity network.

Remittance and payment analytics. Revenue cycle analytics platforms and payment posting tools need remittance data to close the financial loop after adjudication. get_remittance_advice and list_payments retrieve payment records and remittance advice with adjustment codes and denial reasons. For a revenue integrity platform that needs to reconcile payments across payers running through Availity, this data is the input the analytics layer requires.

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RCM Workflows This Integration Covers

The ten planned actions span the provider-payer transaction workflows that Availity's network manages:

• Eligibility verification: check_eligibility submits a real-time inquiry for a patient against a specified payer. get_eligibility_response returns coverage details, deductible balances, copay amounts, and in-network status for the patient's active plan.
• Claims management: submit_claim sends professional and institutional claims to designated payers through Availity. get_claim_status retrieves adjudication status and rejection codes. list_claims returns paginated claim records filtered by date, payer, and status.
• Prior authorization: submit_prior_auth initiates a PA request through Availity's portal for a procedure or service. get_prior_auth_status returns the authorization decision including approval, denial reason, and payer reference number.
• Remittance and payments: get_remittance_advice retrieves remittance batches from payers with payment amounts and adjustment codes. list_payments surfaces electronic remittance payments with deposit dates and payment totals.
• Patient financial data: get_patient_balance retrieves the outstanding patient responsibility after payer adjudication and remittance posting.

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Adjacent Integrations

Integuru already covers several of the EHR platforms whose practices transact through the Availity network. The athenahealth integration guide covers the MDP partner program barrier for one of Availity's largest connected EHR platforms, with eleven planned actions spanning patient records, appointments, clinical notes, and billing data. The Kareo integration guide addresses the billing and clinical workflow gap for independent practices on Tebra. The eClinicalWorks integration provides 5 live actions in production spanning patient demographics, insurance data, document management, and patient creation.