Challenges We Solve
Turning compliance into a competitive advantage for payers
At 1upHealth, we help health plans turn CMS interoperability mandates into opportunities for long-term value. The 1up Platform delivers a cloud-based, FHIR-native foundation that simplifies compliance, streamlines operations, and enables more personalized, data-driven experiences for both members and providers.
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
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)