Largest provider of CMS APIs to leverage cutting-edge tech and regulatory expertise to guide payer market to meet new requirements for APIs and Prior Authorization

BOSTON, MA / ACCESSWIRE / January 18, 2024 / 1upHealth, the leading FHIR® platform provider for claims & clinical data acquisition, exchange & compute, will offer support to health plans as they adapt to the CMS Interoperability and Prior Authorization final rule for MA Organizations, Medicaid and CHIP Managed Care and State Agencies, FFE QHP Issuers, MIPS Eligible Clinicians, Eligible Hospitals and CAHs Rule (CMS-0057). 1upHealth will provide its unmatched regulatory expertise in FHIR APIs to lead payers and the broader healthcare industry toward compliance with the new rule ahead of the January 2027 deadline.

"As CMS has proposed and refined interoperability rules over the years, the industry has supported the improvements and innovations these shifts will unlock while preparing how to develop and adopt the practices and technologies required for this data transformation," said John Budaj, VP of Information Technology at Fallon Health. "1upHealth was instrumental in navigating the first batch of interoperability regulations, and we are deeply grateful to have their unparalleled FHIR API expertise in our corner as we work to meet these new requirements around prior authorization and patient data access. Fallon Health is invested in not only meeting the CMS regulations but unlocking the opportunities that interoperability creates for the betterment of our provider partners and ultimately translating into better care and services for our members."
With over 75 enterprise customers including leading national and regional health plans and more than 20 state Medicaid agencies, 1upHealth has the most implementations of CMS APIs in the market. The company is poised to play a key role in the forthcoming interoperability journey, helping payers ensure compliance and maximize value from interoperability investments.

The second wave of CMS payer mandates, which builds off of the previous set of rules, includes provisions to enable value-based care data sharing by improving patient and provider access to health information, and streamlining processes related to prior authorization for medical items and services, all by migrating to FHIR-based APIs. Unlike previous rules, which included patient-mediated APIs that required individual member action, the new rules are population-level Business-to-Business (B2B) APIs and are expected to get significantly higher adoption and traction. The final rule includes several key parameters, including a heavier focus on prior authorization, as evidenced by the inclusion of prior authorization data as part of the Patient Access API, as well as the establishment of the Prior Authorization API. It also markedly includes the complete overhaul of the Payer-to-Payer Data Exchange requirements, as well as the inclusion of the Provider Access API.

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