This page highlights the requirements for health plans under CMS’s recently announced regulation in the Interoperability and Patient Access final rule (CMS-9115-F). This rule is focused on driving interoperability and patient health data access for health plans including Medicare Advantage (MA), Medicaid, CHIP, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs). 1upHealth is already working with health plans to ensure they meet all these regulatory requirements. See our discussion on this rule during our Virtual Health Conference March 11, 2020 with Alexandra Mugge, CMS Deputy Chief Health Informatics Officer here.
This rule requires certain health plans to implement additional technology to improve interoperability and exchange of information.
The Patient Access API is the greatest technical and operational requirement for health plans. It requires claims and encounter information, including cost, as well as a defined sub-set of the members’ clinical information be made available to third-party applications of their choice via a secure HL7 FHIR (Release 4.0.1) API endpoint. Mandate details:
Health plans must make available a FHIR API based list of providers that are in-network. This is the same approach we’ve taken with the public NPPES provider directory FHIR API already on the 1up platform. Mandate details:
Payers are required to exchange patient data at the member’s request so members can take all their data with them as they move between payers. This is the only payer requirement due to take effect in 2022. The USCDI data set is basically FHIR resources with specific attributes and coding terminologies required. We propose building on top of the FHIR APIs from the Patient Access API requirement to support this requirement for payers and their members. Mandate details:
1upHealth is well positioned to support health plans in meeting the CMS requirements for the July 2021 deadline.
We have direct experience through our work with as one of the first approved Blue Button 2.0 apps, with health plans supporting millions of health plan members and the Da Vinci Project through workgroups and connectathons.
We've worked with 100s of health systems across the US in meeting Meaningful Use 3 (MU3) requirements. We’ve now connected to 10,000+ hospital and health centers, allowing patients to authorize access to their EHR medical records with 3rd party applications.
Our team is comprised of leading FHIR experts who have presented alongside CMS and ONC leaders like Don Rucker, had led HL7 standard balloting, and participate in numerous FHIR connectathons
Because our award-winning FHIR solution is already in production, we can ensure timely deployment and meeting the requirements of the new rules.