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.
Prior Authorization
What We're Solving For
Prior authorization processes remain a significant source of friction for both providers and payers, resulting in delayed care, increased administrative costs, and poor member satisfaction. Disconnected systems and manual reviews slow down decision-making and increase provider frustration.
1up Solution
The 1up Electronic Prior Authorization solution automates prior authorization from end to end within existing clinical workflows. It integrates seamlessly with any utilization management vendor or policy system, intelligently routing requests and connecting data across systems in real time. This simplifies operations and accelerates care delivery while reducing the burden on providers and payers.
Value
- Reduce administrative costs and manual reviews
- Shorten decision turnaround times and accelerate member access to care
- Improve provider satisfaction through automation and transparency
Who it's for
- Payers seeking to modernize their prior authorization processes
- CMS-covered payers with lines of business in Medicare Advantage, Medicaid, Children’s Health Insurance Programs (CHIP), and Qualified Health Plans (QHP)
What's included
- CRD, DTR, & PAS FHIR APIs
- Prior Authorization Usage Reporting
- Intelligent Routing Engine
- UM Integration
- CRD Server (Optional)
- Provider Network
- Provider Registration & Onboarding
- Real-Time Event Streams
Payer-to-Payer Data Exchange
What We're Solving For
When members change plans, payers often struggle to access complete historical data needed to manage risk, quality, and continuity of care. Manual data exchanges (if they exist at all) lead to inefficiencies, data inconsistencies, and administrative overhead, ultimately delaying insights and increasing costs.
1up Solution
The 1up Payer-to-Payer Data Exchange solution automates data exchange between payers, building a complete, longitudinal member profile from day one. It leverages the industry’s largest network of payer endpoints and deep integrations with UM and care management systems to trigger real-time workflows and improve continuity of care.
Value
- Accelerate member onboarding and ensure data accuracy
- Enhance member experiences by enabling seamless care transitions
- Improve risk adjustment and quality measures with complete member histories
Who it's for
- Payers focused on improving onboarding, risk, and quality programs
- CMS-covered payers with lines of business in Medicare Advantage, Medicaid, Children’s Health Insurance Programs (CHIP), and Qualified Health Plans (QHP)
What's included
- P2P FHIR APIs
- Consent Management (IdP or Email)
- Cost & Sensitive Data Filtering
- Member Matching
- Clinical & Member Services System Integrations
- P2P Network
- Payer Registration & Onboarding
- Longitudinal Member Profile
- P2P Usage Reporting
Provider Access
What We're Solving For
Providers require timely access to accurate member data to enhance the quality of care, minimize waste, and reduce costs. Manual file exchanges, batch transfers, and inconsistent processes lead to inefficiency, higher costs, and provider dissatisfaction.
1up Solution
The 1up Provider Access solution automates data sharing with in-network providers, integrating directly into existing workflows via EHRs, provider portals, or a lightweight, 1up-hosted interface. Granular data controls, usage reporting, and simplified attribution give payers complete data visibility and control.
Value
- Reduce administrative burden and costs for both payers and providers
- Strengthen provider relationships through data transparency
- Improve coordination and performance in value-based programs
- Deliver better member outcomes with timely, actionable data
Who it's for
- Payers supporting large or multi-network provider ecosystems
- CMS-covered payers with lines of business in Medicare Advantage, Medicaid, Children’s Health Insurance Programs (CHIP), and Qualified Health Plans (QHP)
What's included
- Provider Access FHIR APIs
- Attribution Ingestion
- Consent Management (IdP or Email)
- Cost & Sensitive Data Filtering
- Provider Registration & Onboarding
- Integrated Provider Experience
- Provider Access Usage Reporting
Patient Access
What We're Solving For
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 challenging and piecemeal process for members, often resulting in significant manual work and administrative burden for payers.
1up Solution
The 1up Patient Access solution automates data sharing with members by enabling secure access to their health information via third-party apps of their choice. A fully managed app ecosystem, including registration, vetting, and authorization, along with flexible authentication options, makes it simple for members to connect and share data securely.
Value
- Enhance member satisfaction and engagement through digital data access
- Reduce administrative overhead and support costs
- Enable more personalized, data-driven member experiences
Who it's for
- Payers investing in digital transformation and member engagement
- 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 with Patient Access requirements for commercial plans (e.g., California & Tennessee)
What's included
- Patient Access FHIR APIs
- Auth App (IdP or Email)
- Patient Access Usage Reporting
- Third-Party App Network
- Third-Party App Registration & Onboarding
Provider Directory
What We're Solving For
Maintaining accurate and up-to-date provider directories is a resource-intensive and error-prone task. Inaccurate listings cause member frustration, increase call volume, and reduce provider visibility, all while incurring additional administrative costs.
1up Solution
The 1up Provider Directory solution automates the ingestion, validation, and publication of provider data. Continuous synchronization ensures that directories remain accurate and accessible, improving transparency and reducing operational load.
Value
- Reduce the cost and complexity of directory maintenance
- Improve accuracy and member trust
- Enhance provider visibility and satisfaction
Who it's for
- Payers maintaining large or multi-network provider directories
- CMS-covered payers with lines of business in Medicare Advantage, Medicaid, Children’s Health Insurance Programs (CHIP), and Qualified Health Plans (QHP)
What's included
- Provider Directory FHIR API (no authorization required)
- Provider Directory Usage Reporting
Formulary
What We're Solving For
Members and providers often face uncertainty regarding drug coverage, costs, and formulary alternatives, which can lead to confusion, delays, and unnecessary administrative calls.
1up Solution
The 1up Formulary solution standardizes and simplifies access to drug coverage information. Members and providers can easily view covered medications, alternatives, and pricing information within connected apps or portals, improving decision-making and satisfaction.
Value
- Increase transparency into drug coverage and costs
- Reduce member and provider confusion and call center volume
- Support medication adherence and overall member satisfaction
Who it's for
- Payers offering pharmacy benefits or integrated medical-drug coverage
- 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
- Formulary FHIR API (no authorization required)
- Formulary Usage Reporting