1Up Comply

1up Comply

Meet current and future health data exchange regulations

    For
    • Payers
1up Comply

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

Our FHIR API easily integrates with third-party applications, enabling active members of CMS-regulated health plans to use the application of their choice to access and share their clinical, claims, encounter, and prior authorization data. Authorized third-party apps are granted read-only access to the APIs, and members can use their insurance credentials to enable data-sharing. Payers can use 1up reporting tools to generate and share yearly required patient usage metrics with CMS.

This configurable front-end solution allows payers to share and receive clinical, claims, encounter, and prior authorization data with other payers through FHIR APIs for new and previous members who have opted into data sharing—excluding cost-sharing and remittance dollar amounts. Data received from other payers is securely integrated with existing member data for a more comprehensive view of the member base.

Our FHIR API 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 provider’s request. In-network providers register on the 1up FHIR platform to receive read-only API permissions and OAuth 2.0 access tokens for regular FHIR API data retrieval. Payers can filter out cost dollar amounts in the API for individual providers.

1upHealth is implementing a standards-based solution to automate approvals by making the prior authorization rules computable and acting as the FHIR API intermediary—connecting providers to the payers’ business and clinical rules and their existing UM systems.

 

Our Prior Authorization solution for payers will follow the Da Vinci requirements for FHIR-based APIs, including:

 

  • Coverage Requirements Discovery (CRD) API to determine if prior authorization is necessary for a given service or procedure
  • 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

A public FHIR API that exposes directories of in-network providers, organizations, and pharmacies of CMS-regulated health plans with third-party applications.

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.

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