Challenges We Solve​

Addressing today’s toughest health data challenges, enabling tomorrow’s possibilities

At 1upHealth, we help our clients solve an endless array of health data-related challenges – from meeting CMS regulations to forward-looking opportunities that use data as a competitive advantage – with our 1up FHIR Platform and suite of products. We’ve included a few examples below. Contact us today to discuss your unique health data challenges.

Patient Access Compliance

What we're solving

Members deserve easy access to their complete health records and the ability to share them with third-party applications of their choice. However, accessing existing health data is a difficult and piecemeal process for members and often creates a lot of manual work and administrative burden for payers.

Designed to meet CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) requirements and leveraging industry standards, the 1upHealth Patient Access API streamlines this process and eliminates the manual burden of sharing data with members. Our FHIR-based API easily integrates with third-party applications, enabling members to use the application of their choice to access and share their clinical, claims, encounter, and prior authorization data. This automated process accelerates data sharing, improves member experience, and saves payers significant time and money.

Who it's for

  • CMS-covered health plans with lines of business in Medicare Advantage, Medicaid, Children’s Health Insurance Programs (CHIP), and Qualified Health Plans (QHP)
  • Health plans in certain states, including the State of California, with Patient Access requirements for commercial coverage
  • Forward-looking payers interested in offering this service as a competitive advantage

What's included

  • Non-FHIR and FHIR data ingestion
  • OAuth2 for the member to authenticate and authorize data sharing
  • Patient Access API to expose the data when shared
  • Reporting of patient access events 
  • App registration and management as part of app gallery

Learn more by visiting the Patient Access API page.

Payer-to-Payer Data Exchange

What we're solving

As payers acquire new members, they need access to the member’s historical data to better inform care management, ensure continuity of care, create more targeted member experiences, and support operational priorities like risk adjustment and quality measures. But, acquiring historical data from other payers is challenging, fraught with inefficient, manual processes and inconsistent data formats—leading to high administrative costs.

 

Designed to meet CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) requirements and leveraging industry standards, the 1up Payer-to-Payer Data Exchange API lets payers easily and securely exchange member data in a standardized format—eliminating manual processes and administrative costs. Our FHIR-based API allows payers to share and receive health data for new and previous members who have opted into data sharing, excluding cost-sharing and remittance dollar amounts. Incorporating data from other payers gives a complete view of a payer’s member base and supports more informed and efficient decision-making.

Who it's for

  • CMS-covered payers with lines of business in Medicare Advantage, Medicaid, Children’s Health Insurance Programs (CHIP), and Qualified Health Plans (QHP)
  • Payers in certain states, including the State of California, with Patient Access requirements for commercial coverage
  • Forward-looking payers interested in offering this service as a competitive advantage

What's included

  • Non-FHIR and FHIR data ingestion 
  • Send API to move historical data to current plans in FHIR
  • OAuth2 for the member to authenticate and authorize data sharing
  • Patient matching
  • Optional bulk FHIR data export to export data from the FHIR server

Learn more by visiting the Payer-to-Payer Data Exchange API page.

Provider Access

What we're solving

Providers across multiple business models where data sharing rules apply need a holistic view of the patient, including a payer’s rich claims history, to improve the quality of care, reduce waste, and decrease costs. Unfortunately, today, sharing member data with in-network providers is time-consuming, inefficient, and costly for payers—often relying on manual processes that do not scale and impede data exchange, like sharing flat files.

Designed to meet CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) requirements and leveraging industry standards, the 1up Provider Access API eliminates these manual processes, making it easy and cost-effective for payers to share data with providers. Our FHIR-based API ensures providers get timely and standardized data, enabling them to improve their quality measure performance and ultimately saving payers money.

Who it's for

  • Payer, specifically Medicare Advantage (MA)
  • Medicaid
  • Children’s Health Insurance Program (CHIP)
  • Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs).

What's included

  • A FHIR API allowing providers to access data on health plan members with whom the provider has an active care relationship. 
    • Ex: Provider A and Payer B  are business partners.Provider A would call the 1up FHIR API and return data for Payer B members who are attributed to Provider A. 

 

Learn more by visiting the Provider Access API page.

Prior Authorization

What we're solving

Payer utilization management teams need an automated and standardized approach to handling prior authorizations with in-network providers. However, today, prior authorization relies on disparate, manual intake channels, resulting in undue operational costs, delayed patient care, and provider burden.

 

1upHealth’s Prior Authorization API solution automates the prior authorization process using standard FHIR-based APIs to connect in-network providers with payer prior authorization rules and existing utilization management systems. By shifting from point-to-point connectivity with individual providers to centralized connectivity with 1upHealth, payers can streamline processes, realize cost savings, improve member outcomes, and significantly reduce provider burden.

Who it's for

  • Medicare Advantage (MA)
  • Medicaid
  • Children’s Health Insurance Program (CHIP)
  • Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs)

What's included

  • Coverage Requirements Discovery (CRD) API
  • Documentation Templates and Rules (DTR) API
  • Prior Authorization Support (PAS) API
  • Pre-packaged analytics on a payer’s prior authorization “performance”

*Contingent upon requirements included in final CMS rule

Provider Directory Compliance

What we're solving

Our FHIR-based Provider Directory API enables payers to share information on in-network providers as part of the Patient Access Final Rule using public-facing APIs.

Who it's for

  • CMS-covered health plans with lines of business in Medicare Advantage, Medicaid, Children’s Health Insurance Programs (CHIP), and Qualified Health Plans (QHP)

What's included

  • Non-FHIR data ingestion and conversion to FHIR
  • Provider Directory API to expose the data publicly (no authorization required)

Clinical & Claims Data Aggregation

What we're solving

1upHealth enables healthcare organizations to move all of their different data types – including CCDA, HL7v2, flat files, and more – into the 1up FHIR Platform for ingestion, mapping, and storage in the FHIR standard and then enables them to perform the data analysis needed to make decisions that power their business. 

Who it's for

  • Payers
  • Providers/ACOs
  • Digital Health

What's included

  • EHR FHIR connectivity
  • Non-FHIR (CCDA, HL7v2, payer claims) and FHIR data ingestion
  • Map and store in FHIR environment
  • Managed service
  • Query and access data by easily integrating it into existing analytics systems – including SQL, Tableau, and PowerBI – and business workflows

Population-Level EHR Data Access

What we're solving

We help healthcare organizations of all kinds extract population-level data from EHRs so they may perform a range of actions, such as run analytics, make coverage decisions, manage utilization, supplement data for HEDIS, complete value-based care contracting and reporting, and much more.

Who it's for

  • Payers
  • Providers
  • Life Sciences 
  • Digital Health

What's included

  • Patient roster upload
  • Manages the connection to EHR endpoints
  • FHIR ingestion of EHR data
  • Ingestion of clinical data in non-FHIR formats (HL7, CCDA) and conversion to FHIR
  • Bulk FHIR data export if you choose to export your data from the FHIR server

Patient-Mediated EHR Access

What we're solving

1upHealth helps healthcare organizations of all kinds to enable their customers to move their clinical data anywhere. Patient-Mediated EHR Access makes getting the data over easier, reducing significant administrative burden. 

Who it's for

  • Payers
  • Providers
  • Life Sciences 
  • Digital Health

What's included

  • FHIR ingestion from EHR FHIR API
  • OAuth2 for the member to authenticate and authorize data sharing
  • Patient matching 
  • Bulk FHIR data export if you choose to export your data from the FHIR server