2023 Best In KLAS CMS Payer Interoperability

Prior authorizations for referrals and clinical procedures are widely acknowledged as a significant pain point for all involved parties—payers, providers, and patients. Using implementation guides from HL7’s Da Vinci Project, the collaborators in this case study created bidirectional data exchange through a FHIR API that enables an automated, in-workflow authorization process. The pilot use cases have been successful, achieving improved efficiency, reduced costs, and—most critically—more timely care and improved patient outcomes.

White Paper

CMS Payer Interoperability

04 August 22 | Joe VanDeGraaff and Ruirui Sun

To enable patients to securely transfer their data from payer to payer as their coverage changes, new mandates dictate that CMS-regulated payers must be able to securely exchange patient data. Several technology vendors are available to help health plans and state agencies comply with these interoperability requirements, providing capabilities such as patient access APIs, provider directory APIs, and payer-to-payer data exchange. This vendor guide is intended to help health plans and TPAs understand the vendor technology options; it includes those vendors known to KLAS as of July 2022.

In 2021, new CMS rules came into effect that require CMS-regulated health plans to have a patient access API and a provider directory API. Aimed at increasing the interoperability of personal health data, these rules have prompted payers to look at new ways of sharing external information. This report evaluates 1upHealth‘s FHIR Platform, an interoperability solution designed to help payer customers meet governmental regulations and improve consent and authorization management.

Company/solution	Overall performance score (100-point scale)	Total evaluations	Trend (2022-2023)	Culture	Loyalty	Operations	Product	Relationship	Value

Edifecs XEngine Server For FHIR	87.9	n=9	N/A	A-	A-	B	A-	B	A-

1upHealth FHIR Platform	86.8	n=14	N/A	B-	A	B	B+	B+	A

Smile Digital Health Smile Digital Health	84.8	n=12	N/A	B	A-	C+	B+	B	B

InterSystems HealthShare CMS Solution Pack	82.2	n=6	N/A	C+	B	C	B	B+	A-
	50.0	100.0

Company/solution	Trend (2022-2023)	Culture	Loyalty	Operations	Product	Relationship	Value

Edifecs XEngine Server For FHIR 87.9 n=9 COMMENTS	N/A	A-	A-	B	A-	B	A-
1upHealth FHIR Platform 86.8 n=14 COMMENTS	N/A	B-	A	B	B+	B+	A
Smile Digital Health Smile Digital Health 84.8 n=12 COMMENTS	N/A	B	A-	C+	B+	B	B
InterSystems HealthShare CMS Solution Pack 82.2 n=6 COMMENTS	N/A	C+	B	C	B	B+	A-

CMS Payer Interoperability

Past CMS Payer Interoperability Awards

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