Payer Services for Regulatory Compliance & Interoperability

Your Path to Regulatory Compliance and Operational Value

The transition to value-based care has been under way for more than 3 decades, but progress has been slow, in part due to inadequate digital infrastructure to support collaboration and data sharing. Hence efforts by the US government to use regulatory levers to build out the needed framework.

The HITECH act digitized and normalized provider EHR data. CMS-9115-F introduced API-based information sharing by payers. Now, “CMS Interoperability and Prior Authorization Final Rule” (CMS-0057-F) has set in place the third leg of a framework using mandates to advance interoperability and automate costly manual prior authorizations.

Whether your organization views these mandates as a burden to be shouldered, or a strategic investment to be embraced, InterSystems Payer Services offer a path to operational value and a foundation on which to build toward market leadership, all while supporting your compliance and value-based care journey.

Supporting Mandated Interoperability

InterSystems HealthShare CMS Solution Pack supported the mandates laid out in the CMS Interoperability and Patient Access Final Rule (CMS-9115-F), including the adoption of HL7® FHIR® by payer organizations.

To help US health insurers address the Interoperability and Prior Authorization rule, InterSystems is updating our product offerings to support mandated information sharing with InterSystems Payer Services.

The latest rule requires:

Information sharing between payers via a Payer-to-Payer API

Expands and replaces the payer-to-payer information sharing initiated with CMS-9115-F. The new version requires a FHIR API for use in sharing 5 years of patient data, including information about prior authorization requests. Shared data must be integrated with other data maintained by the payer. Members must be able to opt into this information sharing.

Payer to provider information sharing via a Provider Access API

Deployment of a FHIR API for payers to share member data they maintain with in-network providers with whom the member has a treatment relationship. Patients must be able to opt out of this sharing. Note that the rule indicates that the payer will share all the structured data it has aggregated from other payers.

Expanded information sharing with members via an updated Patient Access API

An extension of CMS-9115-F FHIR-based patient access requirements for download to third party applications. The API now includes prior authorization data. Again, the rule indicates that the payer will share all the data it has aggregated from other payers. Payers must also report metrics to CMS annually on the use of this API.

Streamlined business processes using a Prior Authorization API

This API supports electronic prior authorization. The rule strongly recommends use of the processes and Implementation Guides (IGs) developed by the HL7 Da Vinci projects using FHIR APIs. It includes aggressive turnaround times to respond to requests, and public reporting of key metrics on the payer’s website at least annually.

Note that there are also extensive operational processes to be put into place, as well as incentives for provider participation in prior authorization. The effective date for the four APIs is January 1, 2027, while reporting and other portions of the rule go into effect January 1, 2026.

InterSystems Payer Services expands and replaces the HealthShare CMS Solution Pack and delivers extensive additional functionality to address the technical components of these new requirements.

From APIs to Longitudinal Health Records, Steppingstones to Your Enterprise Data Strategy

InterSystems Payer Services are designed to maximize your data infrastructure investment options. Together with HealthShare Unified Care Record®, they offer robust and comprehensive capabilities on which to expand or build your enterprise data infrastructure. You can choose the package that best fits your immediate needs and add others as you are ready.

InterSystems Payer Services connect and interact with your existing systems for prior authorization. All are available as managed cloud services or on premises. And all conform to the relevant ONC, CMS, and HL7 Da Vinci specifications and Implementation Guides (IGs).

InterSystems Payer Services Offering

InterSystems Payer Services

CDex

The HL7 FHIR Da Vinci Clinical Data Exchange Implementation Guide (CDex IG), enables payers to request information from provider organizations. This provides a way for payers to get answers to targeted questions to address a number of use cases. One common one is automating or reducing the effort for performance measurement.

ePrior Authorization

Packaged API services and infrastructure to connect your existing backend systems with your provider partners for electronic prior authorizations. ePrior Authorization is an implementation of the HL7 FHIR Da Vinci Prior Authorization workflow in conformance with the recommendations in the Final Rule. Note that while the rule refers to a singular API, it encompasses multiple Da Vinci IGs.

Da Vinci Prior Authorization Implementation Guides - Coverage Requirements Discovery (CRD) , Documents Templates and Rules (DTR), Prior Authorization Support (PAS).
Required metrics on prior authorizations supported by the API.
CDex provider to payer data exchange.

Data Exchange

Support for the three “access APIs” as well as provider to payer data exchange.

Payer-to Payer API, including member matching.
Provider Access API, including prior authorization data.
Patient Access API for use in downloading health records, including prior authorization data, to third party applications. Includes required metrics for reporting to CMS.
CDex provider to payer data exchange.
Provider attribution support for use with the Provider Access API.
Member opt-in and opt-out support for use in payer-to-payer and payer-to-provider information sharing.

Interoperability

Comprehensive support for the technical requirements of CMS-0057-F. This offering is intended for organizations with an existing CMS-9115-F solution and FHIR support. It combines the ePrior Authorization and Data Exchange capabilities in a single licensed package.

Advanced Interoperability

Comprehensive support for the requirements of both CMS-9115-F and CMS-0057-F. This includes everything in the InterSystems Payer Services Interoperability service, plus:

A limited license version of HealthShare Unified Care Record to store and view applicable longitudinal claims and clinical patient data.
Opt in for members to allow or deny access to information sharing.
A limited license version of Provider Directory.

Note that some elements of CMS-9115-F, but have been significantly expanded or updated for CMS-0057-F. For example, the Patient Access API now includes information on prior authorizations, and payer-to-payer information sharing has been replaced by the FHIR-based Payer-to-Payer API. In such instances, CMS-0057-F specifications take precedence.

“We are creating a unified view of our members’ whole health across the clinical considerations, across administration data, across behavioral health and social determinate considerations as well. That’s the basis for every other piece of innovative work that we have in our digital transformation strategy. It’s an essential enabler of those efforts.”

Business Transformation Manager
Arkansas Blue Cross Blue Shield

The Gold Standard:
HealthShare Unified Care Record

While InterSystems Payer Services offer the flexibility to address targeted requirements for information sharing, only HealthShare Unified Care Record supports both information sharing AND a comprehensive longitudinal health record.

Payer-to-payer data exchange requires that payers maintain all the data they hold about a member to be shared with other payers. This information is also what is expected to be shared with members to help them manage their care, and with providers, for care coordination and management.

HealthShare Unified Care Record has been the gold standard for aggregating clinical, claims, social determinates of health (SDOH) and other data types into comprehensive longitudinal health records for years. In addition to supporting basic activities called out in CMS-0057-F, when part of a long-term architectural framework, it can be used to:

Reduce the cost of data acquisition for quality and performance measures.
Sustain and improve quality scores, e.g., reducing care gaps, tied to payment incentives.
Evaluate performance for existing products such as Medicare Advantage offerings, and for designing new ones.
Evaluate network adequacy for plan design and performance.
Support performance and strategic planning analytics requirements, e.g., population health management.
Reduce provider and member abrasion with an improved and efficient experience, including providing low touch and self-management tools to patients to reduce the cost of treatment/reduce need for services.

A full license for HealthShare Unified Care Record will support compliance with CMS-0057-F. For organizations requiring full support for CMS-9115-F, a subscription will also include limited licenses for HealthShare® Provider Directory, HealthShare® Patient Index, and InterSystems® IRIS for Health™.

InterSystems Payer Services are delivered as a cloud service, fully managed by InterSystems. They are also available on prem. And when you select InterSystems Payer Services, you get more than technology. You also get our acclaimed customer support. Learn more about InterSystems and its work with public and private payers.

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