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1up Comply
Meet current and future health data exchange regulations
- For
- Payers
Featured How-to Guide
Payer’s Playbook: CMS Interoperability Final Rule
How to set the foundation for a seamless tech implementation
Keeping up with health data exchange regulations on your own isn’t easy.
Meeting constantly changing government regulations around healthcare data exchange is complicated. You need a partner who stays up-to-date with regulatory requirements, advises on best practices, and delivers an API-enabled, FHIR®-native solution that scales and evolves over time.
Meet CMS regulatory rules and state-specific requirements
1up Comply enables payers to meet regulatory requirements for health data exchange and powers your data analytics. Make the move to a partner that’s helping 80+ healthcare organizations comply with existing regulations, while also achieving ROI from interoperability investments.
Beyond today’s regulations, we’re getting ready for what comes next, including Prior Authorization and Provider Access API.
1upHealth APIs powering data exchange compliance
Prior Authorization
To support the latest tCMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) requirements for electronic Prior Authorization, our product roadmap includes a Prior Authorization solution for payers following the Da Vinci requirements for FHIR-based APIs, including:
- Coverage Requirements Discovery (CRD) API to determine if prior authorization is necessary
- Documentation Templates and Rules (DTR) API to discover the clinical documentation requirements and compile necessary information from the provider’s system
- Prior Authorization Support (PAS) API to receive prior authorization submissions and send responses on status, approvals, and denials
Payer-to-Payer Data Exchange
A configurable front-end solution that allows active members of CMS-regulated health plans to authorize the transfer of their clinical data from their former plan(s) to their current plan in the FHIR format; Send API built on top of the CMS Rule for other payers to securely pull clinical data from. Updates to our Payer-to-Payer solution are on the product roadmap to support the latest CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) This includes expanding the scope of data exchange from clinical data only to include claims, encounters, and prior authorization data and shifting from an exclusively patient-mediated workflow to an opt-in model.
Patient Access API
A FHIR API that enables active members of CMS-regulated health plans to share claims, encounters, clinical, and formulary data with third-party applications of their choice. To support the latest CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), updates to this API are on the product roadmap, particularly the inclusion of prior authorization data.e inclusion of prior authorization data.
Provider Access API
A FHIR API that delivers active, attributed member data into a provider’s EHR, practice management system, or any other tech solution utilized for treatment purposes within one (1) business day from the request for such information by the provider. To support the latest CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), delivery of a Provider Access API is on the product roadmap, starting with the ability of a payer to export data to a provider on a group of patients via FHIR API or as a flat file.
Provider Directory API
A public FHIR API that exposes directories of in-network providers, organizations, and pharmacies of CMS-regulated health plans with third-party applications.
Formulary API
A public FHIR API that exposes Formularies or Preferred Drug Lists of CMS-regulated plans with third-party applications.
Deep Expertise in Health Data Exchange Regulations
1upHealth’s regulatory strategy is informed by our Chief Strategy Officer Don Rucker, MD who literally wrote the book on healthcare interoperability. Prior to joining 1upHealth, Don served as the National Coordinator for Health IT at the US Department of Health and Human Services (HHS), where he led the development and issuance of the ONC’s 21st Century Cures Act Final Rule, which supports patient access and interoperability of health data. He brings this deep expertise to 1upHealth, directing product strategy and working directly with our clients to help them achieve their goals. Visit our FHIR Interoperability Resource Center.
