Avalon Healthcare Solutions

Name

Avalon Healthcare Solutions

Legal name

Avalon Health Services, LLC

Website

https://avalonhcs.com

Company type

Private

Founded year

2013

Operating status

Operating

Headcount range

101–250 employees

Ownership category

akta.pro rank

Product category

Healthcare Diagnostic Management Software

NAICS

Computer Systems Design Services (541512), Computer Systems Design and Related Services (5415)

SIC

Services-Computer Integrated Systems Design (7373), Services-Health Services (8000)

akta.pro primary industry

Enterprise Integration Engines & Interface Management (HL7 v2/X12/API) (HLACABAC)

akta.pro secondary industry

Care Navigation, Advocacy & Benefits Guidance Platforms (HLALADAJ)

Keywords

• Lab benefit management
• Diagnostic intelligence platform
• Genetic test management
• Routine test management
• Utilization management services

Headquarters

HQ city

Tampa

HQ country

United States

HQ region

North America

Offices2 records

Markets served

GTM type

B2B

Offering type

Software

Cost components

Technology or R&D, Personnel, Operations, Marketing or Sales, Infrastructure

Revenue model

1. Lab Benefit Management Services: Subscription and performance-based managed services model where Avalon provides end-to-end lab diagnostics management including benefit management, clinical science expertise, and proprietary analytics to health plans. The company processes over 18 million claims monthly through its platform, with pricing likely based on per-member-per-month (PMPM) or a percentage of savings generated.
2. Diagnostic Intelligence Platform: Integrated platform licensing model providing evidence-based policies, curated lab networks, and real-time insights. Delivers 10-20% savings on outpatient lab costs, with value-based pricing aligned to cost reduction outcomes.

Go-to-market motion3 records

Distribution channels4 records

Marketing channels7 records

Core offering

Avalon Healthcare Solutions provides a cloud-based Diagnostic Intelligence platform that enables health plans to manage, validate, and optimize laboratory testing at scale. The platform powers Benefit Management solutions (Routine Test Management, Precision Genetic Test Management, AvalonSelect Genetic Network) and Analytics solutions (Cardiometabolic, Oncology) that combine 130+ evidence-based clinical policies, real-time automated policy enforcement, curated lab networks, and AI/ML-driven insights. The platform processes over 18 million claims monthly and serves 30+ health plans covering 90+ million members nationwide.

Product overview

Avalon Healthcare Solutions offers Diagnostic Intelligence—a platform-plus-modules architecture centered on its proprietary Diagnostic Insights Platform. The platform powers two integrated solution suites: Benefit Management (encompassing Routine Test Management, Precision Genetic Test Management, and the AvalonSelect Genetic Network) and Analytics (including Cardiometabolic and Oncology programs). The core technology includes the patented APEA system for automated policy enforcement processing 18M+ claims monthly. Avalon's solutions serve over 30 health plans and 90 million members nationwide, focusing on ensuring the right diagnostic tests are performed at the right time through evidence-based policies, curated lab networks, and real-time enforcement.

Differentiator

Problem solved

Functional benefit

Products and services

• Diagnostic Insights Platform Cloud-based proprietary platform that transforms fragmented diagnostic processes into a unified, intelligence-driven ecosystem for health plans. Features 130+ evidence-based clinical policies, integrated network management and automation, and real-time insights at scale.
• Routine Test Management (RTM) Automated solution ensuring evidence-based policy adherence for routine lab testing. Evaluates claims post-service and pre-payment in real-time using thousands of rules (CPT codes, age, lab test history, frequency), delivering $1-3 PMPM medical expense savings and 10-20% reduction in outpatient lab spend.
• Precision Genetic Test Management (PGTM) Advanced genetic testing management combining lab science expertise with claims intelligence. Uses DEX Z-Codes for test identification of 40K+ genetic tests assigned to CPT code 81479, automates prior authorization, and delivers $0.50-$0.65 PMPM increased outpatient genetic lab savings with 3:1 ROI.
• AvalonSelect Genetic Network Preferred genetic lab network with 375+ curated lab providers and 150+ contracted labs. Includes Gold Card Program for reduced prior authorization burden, national fee schedules, and quality enforcement standards for genetic testing.
• Oncology Analytics Cancer care analytics program ensuring cost-effective treatment through automated prior authorization, tumor mutation therapy matching, standardized testing protocols, and genetic testing integration. Matches patient tumor genetic profiles to approved targeted therapies, reducing diagnosis-to-treatment time from 40-60 days to 10-15 days, delivering $3-5 PMPM savings from reducing improper drug usage.
• Cardiometabolic Analytics GLP-1 therapy management solution unifying lab, medical, and pharmacy data for risk stratification and resource allocation. Evaluates A1C levels, lipid panels, and cardiovascular risks to identify patients likely to benefit from GLP-1 therapies and optimize cardiometabolic care investments.

Quantifiable outcome

• 10-20% reduction in outpatient lab spend
• +9 more outcomes

Named customers4 records

Segments3 records

Ideal customer profiles3 records

Technology focussed Yes

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

AI capability5 records

Feature7 records

Partnerships

Two partnerships are on record, tiered flagship and minor.

• Sentara Health PlansflagshipStrategic or Co-development Partner · 1 January 2021Expanded partnership since 2021 to implement evidence-based genetic testing management services for Sentara's nearly one million members in Virginia and Florida. The partnership has delivered significant reductions in out-of-pocket lab spending costs while improving healthcare outcomes. Genetic testing management services rollout to commercial plans began December with expansion to other offerings in early 2022.
• NCQA (National Committee for Quality Assurance)minorOthersAvalon earned NCQA Utilization Management Certification and uses NCQA-aligned audit methodology for its Gold Carding Program. NCQA accreditation validates Avalon's utilization management processes meet rigorous quality standards.

Scale indicators12 records

Recent moves7 records

Expansion highlights5 records

Direct peers

• eviCore (Evernorth): Evernorth's lab, radiology, and cardiology benefit management arm - the most directly comparable competitor in lab utilization management for health plans with overlapping policy enforcement and prior authorization capabilities.
• AIM Specialty Health (Carelon Health): Carelon Health's (Elevance) clinical appropriateness and utilization management business - competes head-to-head in lab and genetic testing benefit management with similar evidence-based policy frameworks.
• New Century Health: Oncology benefit management and value-based care company providing prior authorization and care navigation for oncology services - directly comparable to Avalon's Oncology Analytics and therapy matching products.
• Cotiviti: Healthcare payment integrity and analytics vendor with claim-level editing and policy enforcement capabilities - closely comparable to Avalon's APEA platform in technical approach and target buyers.
• Zelis: Healthcare cost management platform delivering payment integrity, network management, and claims analytics - comparable payer-facing value proposition with overlapping claims automation capabilities.

Broad incumbents

• Optum (UnitedHealth Group): Diversified healthcare analytics, payment integrity, and care management giant - existing Avalon partner on genetic testing payment accuracy but also a potential competitor with broader capabilities and scale.
• Quest Diagnostics: Largest US clinical lab provider with growing health-plan-facing benefit management services through Quest HealthConnect - comparable in lab network curation and lab benefit strategy.
• Laboratory Corporation of America (Labcorp): Major US clinical laboratory network with payer-facing lab benefit and utilization services - relevant comparator in lab network scale and diagnostic intelligence commercialization.

Emerging players

• Evolent Health: Value-based specialty care platform serving health plans with oncology, cardiology, and other specialty management - overlapping in specialty utilization management and value-based contracts.
• Health Catalyst: Healthcare data and analytics platform serving payers and providers with population health and quality insights - comparable in analytics platform business model though broader in scope than lab-only focus.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat6 records

Key risks5 records

Key highlights7 records

Customer concentration

• LinkedInlinkedin.com/company/avalon-healthcare-solutions

Compliance2 records

Revenue estimate

Valuation estimate

Number of profiles

Profiles12 records

Funding overview

Funding rounds4 records

Investors4 records

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about Avalon Healthcare Solutions