1up FHIR Platform
1up Patient Connect
1up Population Connect
1up Comply
1up Exchange
1up Analyze
During our recent “CMS-0057 in Action: Strategies for Effective Interoperability & Maximum Impact” webinar, we received several excellent questions from our audience. Here are our responses to those questions.
1. Can you share more information about metrics collection for prior authorization measurement and reporting?
The CMS Interoperability and Prior Authorization final rule (CMS-0057-F) outlines prior authorization metrics and reporting requirements that payers must adhere to starting on March 31, 2026, with a look back at 2025. This includes performance metrics across all prior authorization submission channels, including FHIR and non-FHIR.
To that end, 1upHealth will support reporting on performance for submissions made via the 1up Prior Authorization API, including the percentage of requests approved or denied, the percentage of approvals after appeal, and the time between submission and decision for standard and expedited requests.
Our team will work closely to ensure you have an internal strategy to aggregate performance metrics across all submission channels.
2. Which EHRs have you onboarded onto the 1up platform?
We currently integrate with Epic, athenahealth, and Cerner’s open FHIR APIs. These direct FHIR API integrations allow us to ingest population-level clinical data on patient rosters from any provider site using these EHRs.
3. For prior authorization, what EHR vendors are you working with for integration?
To begin with, we will support integrations with Epic, athenahealth, and Cerner. We are actively working with these EHR vendors to understand their prior authorization roadmap. We are closely tracking their timeline for Da Vinci-compliant Clinical Decision Support (CDS) hooks and native support for the prior authorization APIs at the EHR level. In addition, we are working with them to understand when they’ll be rolling out these technical capabilities to provider sites.
4. Can you go into more detail about the EHR interfacing feature for the Prior Authorization API? Is there any planned EHR interfacing for the Provider Access API?
The 1up Prior Authorization API will be triggered directly from the EHR via Clinical Decision Support (CDS) hooks, and the API responses will be presented to the provider directly in the EHR in the form of card responses.
There are no immediate plans to have the 1up Provider Access API interface with the EHR. Note that the CMS final rule does not require the data to be delivered directly into the provider’s EHR, practice management system, or treatment management software. In fact, given the scope of data being shared, and based on our conversations with providers to date, we anticipate the primary users of the 1up Provider Access API to be internal teams at provider organizations (e.g., population health, risk adjustment) looking to access claims data for downstream consumption, and not the physician at the point of care.
5. Does 1up define and implement the “treatment relationship” for the Provider Access API, or is that left up to the payers?
During implementation, our team will work with you to gather and format an attribution file for ingestion to ensure you only send data to providers who have verified treatment relationships with your members. This file will include your list of members and the provider or PCP to which they are attributed.
To make the process as easy as possible, we’ll provide an extract guide, including the necessary schema for ingestion. Our experienced team will help you format your data and set up an SFTP file transfer at your preferred frequency, depending on how often you update your attribution files.
6. When will the APIs be available?
Availability for each of the 1up Comply APIs varies depending on our product development roadmap. However, they will all be available for testing and go live well before the January 1, 2027 compliance deadline.
- Patient Access: The new and improved CMS-0057 version of our Patient Access API will be available to go live as early as the second half of 2025. This will include new prior authorization data, a better member auth experience, and improved usage reporting. Please note our CMS-9115 version of the 1up Patient Access API is available now and live across our existing payer customers.
- Provider Access:
- The CMS-0057 version of the 1up Provider Access API will be available as early as H2 of 2025. This will include our attribution ingestion pipeline, configurable cost filtering, self-service registration portal for providers, and pre-built API usage reporting.
- We offer an early version of 1up Provider Access API available today, which you can use to sunset your legacy data-sharing mechanisms (sharing flat files) and begin testing the API with friendly providers immediately.
- Starting early and testing the API before the compliance deadline will help ensure this process can scale and that providers have the appropriate expectations for what data they will receive and how to use it. Ultimately, it will help set you up for success when it comes to widespread adoption of the CMS-0057 API version with your entire provider network later in 2025.
- Payer-to-Payer Data Exchange: To comply with CMS-0057, our 1up Payer-to-Payer API will move from a patient-mediated approach to a B2B bi-directional exchange of member data between payers. The new and improved 1up Payer-to-Payer API will be available as early as H2 of 2025, and similar to Provider Access, we recommend that you start testing the API with a friendly payer before exposing it to widespread adoption.
- Prior Authorization: We are partnering with EHR and Utilization Management vendors to enable a seamless, end-to-end prior authorization solution for our customers. Given these necessary integrations, the 1up Prior Authorization API will be available a little later than the other APIs, starting as early as H1 of 2026.
7. For distress hospitals, it’s more difficult for them to invest in FHIR. How does your product help with that barrier to improve the infrastructure for interoperability?
Our modern data platform is built on a standards-based cloud architecture specifically designed for the healthcare industry, making it easy and cost-effective for our customers to acquire, manage, share, and analyze data via FHIR. From leading health plans and state Medicaid agencies to innovative digital health organizations and top-performing ACOs, over 80 health organizations rely on 1upHealth to power their interoperability initiatives. We partner with our customers to ensure a smooth transition – both technically and operationally – and take on all the work of ingesting and converting their data to FHIR.
8. Do you have case studies to demonstrate the ROI related to the efficiency benefits of interoperability and rich data use?
Interoperability doesn’t stop at the FHIR infrastructure and meeting the minimum compliance requirements. To gain true business value and ROI, you need to be able to put your data to work. At 1upHealth, this is a significant focus area for us. We’re working closely with our customers to help them leverage their data for strategic advantage and better decision-making across many use cases.
By enabling seamless data-sharing and real-time communication across systems and stakeholders, interoperability can unlock various financial benefits. Providers and health plans stand to gain from reduced administrative costs, as tasks such as quality reporting and prior authorization processes are streamlined through automation. Additionally, integrating workflows and data-sharing capabilities can lead to more efficient care delivery, enhancing providers’ ability to treat patients through comprehensive, integrated care models, including virtual care settings.
However, while the ROI potential is substantial, calculating specific financial returns at this time remains challenging. The true financial impact of interoperability will become clearer in the coming years as CMS-0057-compliant APIs are more broadly adopted across the healthcare landscape. Nonetheless, the projected benefits in administrative cost reduction, improved care efficiency, and enhanced revenue growth indicate that the long-term ROI for investing in interoperability will be significant.
9. For provider access, how do you get buy-in from both sides?
Payers are already sharing various claims and clinical history data with providers today, especially those with whom they have engaged in value-based care agreements. However, those workflows are fraught with in-efficient, time-consuming, and costly manual processes that do not scale, like sharing flat files. As a result, there are clear benefits for both parties when it comes to improving this data-sharing relationship.
From the provider’s perspective, the data sharing challenges are multiplied because they could have value-based care relationships with ten different payers, including CMS. That’s ten different proprietary flat files they’re receiving every month that require considerable data engineering efforts to make the data consumable and to be able to run analytics on the data. This is time-consuming and resource-intense for the provider and can result in a significant delay between the age of the data they receive and when they can take action on that data.
From our experience, providers are excited to get access to this data faster and in a consistent format. This will eliminate the administrative burden of transforming this data and empower them to take action sooner, ultimately improving their quality of measuring performance with more timely data.
Payers also stand to realize many benefits from provider access beyond just regulatory compliance. FHIR-based data sharing will eliminate the administrative burden on their internal teams to create and share flat files with thousands of providers on a recurring basis. In addition, payers can streamline care coordination with their in-network providers and help to reduce unnecessary tests and procedures with more timely and comprehensive member data.
10. How can we trust the external data received? What validation is performed on new data?
Payers must maintain the ability to share data they receive through subsequent payer-to-payer transactions, but they aren’t responsible for the quality or accuracy of data they only pass along. Regardless of trust, payers are still required to share this data.
That said, trust is crucial for data utilization, but it takes time to build. To help build that trust, we’ll validate all new FHIR data for structural conformance and adherence to the Implementation Guides. We’ve updated our guidance on which versions to use, but we’ll dynamically validate against any version sent to us. Raw data will be stored regardless of quality; however, we’ll offer reports and dashboards for our customers to track data trends and provide filtering options to exclude low-quality data from downstream use.
Watch the “CMS-0057 in Action: Strategies for Effective Interoperability & Maximum Impact” webinar on demand for more information on the 1up Comply product suite, our recommended implementation approach, and use cases beyond compliance.
You can also read our webinar recap blog, “4 Takeaways from the ‘CMS-0057 in Action: Strategies for Effective Interoperability & Maximum Impact’ Webinar.”
