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.

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

Prior Authorization

What we're solving

Payer utilization management teams rely on manual, non-standardized workflows for prior authorization, resulting in undue operational costs, delayed patient care, and provider burden. 

The federal government is addressing these challenges through proposed regulatory measures, which will promote the automation of prior auth and transparency in reporting of approvals, denials, and delays. 

1upHealth is implementing a standards-based solution to automate prior authorization requests 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 Utilization Management (UM) systems. 

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 Access

What we're solving

Providers across multiple business models where data sharing rules apply need a holistic view of the patient, including the rich claims history a payer maintains, to improve treatment, quality, and reduce costs. Today payers share member claims and clinical data with their in-network providers in myriad, inconsistent, and often manual ways (relying on flat files) that do not scale.

1upHealth is building a standards-based solution that will take this burden off the payers and help them comply with the new CMS rules while helping Providers acquire the data they need in a timely and standardized manner. 

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. 

Patient Access Compliance

What we're solving

1upHealth enables payers to meet CMS regulations around patient access to their clinical and claims history and move that data to a consumer app of their choice via our Patient Access API. 

Additionally, payers can use 1upHealth to access patient-mediated data from providers or other payers, without the need for phoning, faxing, or “chart pulling”. 1upHealth enables a modern chart retrieval process by having the member approve the data to flow from provider-to-payer or payer-to-payer via industry standard APIs.

To support upcoming CMS regulations, updates to this API are on the product roadmap, particularly the inclusion of prior authorization data.

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

Provider Directory Compliance

What we're solving

1upHealth provides a FHIR API that enables payers that are required to share information on in-network providers as part of the Patient Access Final Rule to do so 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)

Payer-to-Payer Data Exchange

What we're solving

Payers need to acquire historical data on their members from the members’ previous health plans and to share data on historical members with the members’ new health plans, also known as payer-to-payer data exchange.

As health plans acquire new members, it’s important for them to know as much as possible about their new members’ clinical and utilization histories. Leading health plans are using 1upHealth APIs to acquire data to use in risk adjustment, in-network vs. out-of-network history, care management, and other programs. 

Updates to this API are on the product roadmap to support upcoming CMS regulations. This includes expanding the scope of data exchange from clinical data only to include claims, encounters, and prior authorization data and shifting from an exclusively patient-mediated workflow to an opt-in model.

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

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