Insurance Billing

Overview

The Avara RCM insurance billing module is currently under development and is expected to be available during Q3 2026. It will bring revenue cycle management directly into the Clinical Platform — from verifying coverage before a visit to submitting claims and reconciling payer responses.

This page describes the capabilities planned for launch. Detailed setup and workflow documentation will be added as the module ships.

Planned Capabilities

The insurance billing module will support four core RCM functions:

Prior Authorization

Prior authorization (PA) is advance approval from a patient’s insurance plan before certain services, procedures, imaging studies, or medications are performed. Payers use PA to confirm medical necessity and coverage rules before care is delivered — reducing denials and unexpected patient liability.

In Avara, prior authorization workflows will help your team initiate, track, and document PA requests tied to appointments and clinical orders, so authorization status is visible where scheduling and clinical staff already work.

Prior authorization will also be available in Avara Connect, so referring organizations and your practice can verify authorization requirements earlier in the referral path — before a patient is booked or arrives. That shared visibility cuts back-and-forth between referring and receiving sites and keeps referrals moving without separate phone calls, faxes, or portal logins on each side.

See Referrals for how Connect referral workflows fit into partner scheduling today.

Eligibility Checks

An eligibility check confirms a patient’s active coverage, plan details, and benefit information — copays, deductibles, in-network status, and coverage dates — typically before or at the time of service.

Real-time eligibility reduces front-desk surprises, supports accurate patient estimates, and helps staff confirm the right payer and member ID before claims go out.

Like prior authorization, eligibility checks will be available in Avara Connect as well as the Clinical Platform. Referring partners can confirm coverage context before sending a referral, and your team can re-verify at intake — aligning both organizations on the same payer data and smoothing handoffs between referring and receiving workflows.

Claim Submissions

Claim submission is the process of sending professional or institutional claims to payers (or clearinghouses) for services your organization rendered. A completed claim includes diagnosis and procedure codes, provider and facility identifiers, dates of service, charges, and supporting clinical linkage where required.

The Avara RCM module will support creating and transmitting claims from your Clinical Platform workflow — connecting documentation, appointments, and billing data so claims reflect what was actually performed and documented.

Electronic Remittance Advice (ERAs)

An ERA is the payer’s electronic payment and adjustment response after a claim is processed. ERAs explain what was paid, denied, or adjusted line by line — including reason codes that drive posting, patient responsibility, and follow-up (appeals, corrections, or resubmission).

Automated ERA ingestion will help your team reconcile payments against submitted claims, post adjustments efficiently, and maintain a clear audit trail from charge through remittance without manual re-keying of payer responses.

Transaction Enrollments

End-to-end RCM requires more than software — your organization must be enrolled with payers and clearinghouses to exchange standard healthcare transactions electronically. Avara will support transaction enrollments so you can activate the EDI flows your billing team needs without juggling separate vendor relationships for each step.

Planned enrollment support includes:

• Eligibility — Real-time benefit and coverage inquiries (X12 270/271 transactions) for the eligibility checks described above
• 837P — Professional claim submission (physician and other professional services)
• 837I — Institutional claim submission (facility and hospital billing)
• 837D — Dental claim submission
• 835 — Electronic remittance advice (ERA) — payer payment and adjustment responses paired with submitted claims

Together, eligibility enrollment plus professional, institutional, and dental claim submission plus ERA receipt covers the full revenue cycle path: verify coverage → submit the right claim format for the service → receive and post remittance. Avara will guide enrollment and payer connectivity as part of onboarding so your team can run complete RCM workflows inside the platform once the module launches.

Connect and Clinical Platform Together

Prior authorization and eligibility are where Clinical Platform RCM and Connect intersect most directly. Building both into the referral and scheduling path means:

• Referring organizations can validate coverage and authorization needs upstream
• Receiving practices see consistent payer context when a referral arrives
• Fewer delays from missing PA or stale eligibility at check-in

Claim submission and ERA processing remain centered in your organization’s Clinical Platform billing workflow — where services are rendered, documented, and reimbursed. Connect extends PA and eligibility across organizational boundaries so partner workflows stay as streamlined as in-house ones.

What’s Next

Full insurance billing documentation — payer setup, transaction enrollments, claim workflows, ERA posting, and Connect integration details — will be published when the module launches in Q3 2026. Until then, contact Avara at support@avarasoftware.com if you want to discuss RCM roadmap fit for your organization or early access planning.