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.
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.
*Contingent upon requirements included in final CMS rule
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.
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.
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.
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.
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.
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.
FHIR® is the registered trademark of HL7 and is used with the permission of HL7