To stay ahead in the constantly evolving healthcare sector, payers are adopting digital solutions that put automation and accuracy at the core of every workflow. It’s critical that your Core Administrative Processing System (CAPS) delivers the most up-to-date data available so you can improve automation rates and streamline processes. Our five-part blog series, titled HealthRules® Payer Horizons, demonstrates how our CAPS solution empowers payers to adapt to meet new market opportunities.
Leverage a single solution to improve the member experience
The healthcare industry is shifting toward a value-based care approach, pivoting away from traditional fee-for-service models to focus on improving healthcare outcomes and patient experiences. This transformation is powered by cutting-edge technology and innovative platforms—including HealthRules Payer. Our CAPS solution leverages the latest in AI enablement and cloud-based agility, simplifying the transition to VBC for health plans and elevating member engagement.
1. Provide superior customer service with first-call resolution
Nobody has time to be bogged down by playing phone tag or sitting on a call with slow customer service—especially members trying to navigate their healthcare options. HealthRules Payer recognizes this critical need for speed and efficiency. The platform boasts a Contact Center with a first-call resolution rate of more than 90%. This not only reduces member frustration but also boosts confidence in their health plan. By leveraging HealthRules Payer, health plan leaders can ensure their members are not just satisfied but genuinely pleased with the level of service they receive.
2. Make decisions at the point of care with real-time data
Healthcare decisions are too important to be delayed or based on outdated information. HealthRules Payer empowers health plans to make informed decisions at the point of care by providing real-time member data. This ensures that care providers can access the most up-to-date member information, enabling them to make the best possible decisions for patient care. Access to the most current member information streamlines the process and significantly improves clinical outcomes.
3. Enable self-sufficiency for members seeking cost transparency
One of the most significant barriers to satisfaction and improving member engagement in healthcare is the lack of cost transparency. Members often feel left in the dark about potential costs, leading to frustration and a decrease in trust. HealthRules® Payer addresses this issue head-on by enabling self-sufficiency for members looking for accurate cost information. Through the use of intuitive tools and features within the platform, members can easily compare prices and understand their cost-sharing responsibilities prior to receiving health services. This empowerment leads to a more engaged, informed, and satisfied member base.
4. Improve member satisfaction with faster and more accurate claims payments
The timely and accurate processing of claims is a backbone of member satisfaction. Delays or errors can lead to considerable dissatisfaction and can lead to dissatisfied members. By leveraging HealthRules Payer, health plans can drastically improve both the speed and accuracy of claims payments. The platform’s cutting-edge technology reduces manual processing demands, ensuring that claims are handled efficiently and correctly the first time around. This not only improves the operational efficiency of the health plan but also greatly enhances member satisfaction.
As the healthcare landscape continues to evolve toward a more member-focused, value-based care model, the need for innovative solutions like HealthRules Payer has never been more critical. By providing superior customer service, real-time data for point-of-care decisions, enabling member self-sufficiency, and ensuring faster, more accurate claims payments, HealthRules Payer is transforming the member experience. Health plan leaders looking to stay ahead in this dynamic environment will find HealthRules Payer an indispensable ally in their mission to improve member engagement and satisfaction.
At HealthEdge®, when we think about value-based care, we think about it in two main parts: provider pricing and contracting, and member care delivery. It’s critical that your Core Administrative Processing System (CAPS) is adaptable to your health plan’s changing needs and can integrate with your existing ecosystem to streamline value-based care delivery and payment processing. In our five-part blog series, HealthRules® Payer Horizons, we showcase how our CAPS solution can help your health plan make the most of value-based reimbursements.
Delivering superior customer service – coming soon
Streamline configurations and improve member satisfaction
The pivot to value-based care is not just a trend; it’s a significant shift necessitated by the urgent need to improve healthcare outcomes and patient experiences. The HealthRules® Payer solution suite can help simplify and streamline the transition.
1. Future-proof your plan with AI-enabled, cloud-based software
The move towards AI-enabled and cloud-based solutions represents a bold step away from traditional legacy systems that don’t always have the flexibility payers need to adjust to the healthcare market. This technological evolution enables health plans to adapt quickly to industry changes and regulatory requirements while also offering a scalable and reliable platform. HealthRules® Payer, with its intuitive design and cloud infrastructure, ensures health plans remain future-proof and ready to tackle challenges head-on.
2. Improve user understanding with the HealthRules Language
One of the most daunting aspects of integrating new technologies into your healthcare operations is the learning curve associated with adoption. The HealthRules Language, with its patented, English-like healthcare-specific vocabulary, addresses this challenge head-on. It democratizes the use of the application, making it accessible not just to IT professionals but also to business analysts, claims examiners, and customer service representatives. This universal understanding ensures seamless communication and operation across all departments, a critical component in delivering cohesive value-based care.
3. Quickly configure new benefit plans and contract arrangements
In the realm of value-based care, flexibility and speed are crucial. Health plans need to rapidly configure new benefit plans and adjust contract arrangements to stay competitive and responsive to market needs. The HealthRules Payer’s core administrative processing system and care management workflow solutions empower organizations to do just that. They enable the quick rollout of new products and benefits without the need for custom code or duplication of effort. This strength lies in the HealthRules Language’s ability to transparently define and manage complex configurations with ease.
4. Share actionable data with stakeholders
Value-based reimbursement models thrive on actionable data. The ability to share this data with stakeholders — from providers to members — ensures that everyone involved in the care continuum is informed and engaged. HealthRules Payer, through prospective payment integrity and enhanced member experience features, delivers precise and timely data. Consequently, health plans can make informed decisions, track performance against key performance metrics, and identify areas for improvement with unprecedented precision.
Ultimately, the goal of transitioning to value-based care reimbursement models is twofold: to enhance patient care and to achieve financial sustainability. With HealthRules Payer, health plans are witnessing real, measurable success in these areas. The platform boasts up to 96% billing accuracy even for claims incorporating complex value-based agreements. This accuracy not only mitigates financial risk but also improves customer satisfaction by delivering clear, understandable billing and benefits information.
The constant shifts in the healthcare industry demand innovative solutions, and HealthRules Payer is facilitating a smooth transition to value-based care reimbursement. Its unique blend of AI-enabled efficiency, the HealthRules Language, and configuration capabilities makes it an indispensable tool for health plan leaders aiming to excel in the healthcare market. By adopting HealthRules Payer, payers can ensure better outcomes for their members and set new standards in healthcare delivery.
Do you want to know more about how your health plan can drive quality performance and hit key benchmarks?
In the swiftly evolving landscape of healthcare, staying ahead demands not just understanding the market but redefining the competition. For health plan leaders, navigating these waters involves a delicate balance between scale and agility, particularly when facing off against smaller, more nimble competitors. It’s vital for your Core Administrative Processing System (CAPS) to deliver up-to-date intelligence so you can improve automation and efficiency. Our five-part blog series, titled HealthRules® Payer Horizons, demonstrates how our CAPS solution empowers payers to adapt and take advantage of new market opportunities.
Optimizing value-based care & reimbursement – coming soon
Delivering superior customer service – coming soon
Adapt to shifting healthcare industry demands with HealthRules® Payer
You know the healthcare market, but you need to compete differently than you have before. Smaller competitors are differentiating their offerings through rapid innovation and adaptability. What they may lack in funding, smaller plans make up for in their ability to test offerings on smaller populations and pivot accordingly. They’re also able to take on more manual work due to lower overall claims volumes.
While being responsible for more lives may mean longer implementation times for new initiatives, larger payers often have the resources to invest in comprehensive solutions and strategies that can help expand their business opportunities. HealthRules Payer, gives your health plan the tools to compete more effectively and grow your market share.
1. Establish new contracts faster
In an industry where timeliness is key, HealthRules Payer shines by reducing the set-up time for new contracts to as little as 10 minutes. This efficiency frees up valuable time, allowing health plans to focus more on fostering relationships with new partners rather than being bogged down by backend administration.
Using HealthRules® Promote, regional non-profit health plan expanded lines of business, and grew from operating in four to 12 states in six years. This achievement underscores the platform’s capacity to not just streamline processes but to amplify growth.
2. Configure (and reconfigure) benefit plans in less time
Create virtually any benefit plan or provider contract and start serving new members sooner. The adaptability to swiftly respond to changing market demands and regulatory landscapes is another critical advantage that HealthRules Payer brings to health plan customers. Or platform enables users to create and adjust benefit plans or provider contracts in mere hours or days, significantly reducing turnaround times.
In 2020, a metropolitan non-profit health plan was able to configure and re-configure benefit plans impacted by the COVID-19 pandemic in about two weeks by harnessing the HealthRules® Language. This feature allowed the payer to meet new regulatory requirements and remain focused on members’ well-being.
3. Personalized strategy support
HealthRules Payer is designed to reflect your plan’s unique needs and ecosystem, offering personalized strategy support that aligns with specific organizational objectives and market realities. The HealthRules® Answers feature empowers your team to better leverage real-time data to identify new opportunities as well as reduce costs, assess new offerings, and support modern digital workflows. Our in-house
This tailor-made approach ensures that solutions are not just effective but perfectly suited to each health plan’s individual context.
4. Easily scale to keep up with membership fluctuations
With HealthRules Payer, scalability becomes an operational advantage, enabling health plans to effectively manage membership fluctuations and achieve enrollment accuracy of up to 97%. This level of precision not only enhances operational efficiency but also supports sustained growth and market competitiveness. The combination of technology, strategic partnership, and experienced configuration teams help ensure health plans like yours can achieve their goals in the most timely and cost-effective way.
Do you want to learn more about how HealthRules Payer can empower your health plan to optimize system configurations and optimize business performance?
In early May, HealthEdge hosted the 2024 Clinical Leadership Forum in Boston, Massachusetts. This event brought together more than 50 health plan executives, clinicians, and other healthcare leaders, and served as a platform to address key concerns and opportunities in the industry.
The forum focused on the role of integrated digital health management solutions in driving efficiency, clinical outcomes, and organizational goals by making the most of the resources payers already have. Speakers also discussed the need to embrace the constant change and modernization of the healthcare industry. Health plans across the U.S. are being asked to improve experiences and outcomes without raising costs—and the right digital health solutions can help. In this article, we delve deeper into the discoveries and experiences shared during our exclusive event.
“We need to think about how technology will change our processes to add more value to businesses and customer experiences, and then we have to organize ourselves to change those processes.”
-Steve Krupa, CEO, HealthEdge®
Key Takeaways: We’re being offered the opportunity to change everything we do
The pace of healthcare industry innovation continues to accelerate. Members expect a convenient and personalized experience, regulatory requirements keep shifting, and high-needs populations are growing. Three customer panels stood out for their emphasis on engaging members to improve health outcomes and the member experience.
Address Health Equity Using Digital Care Management
One of the forum’s highlights was a panel led by Dr. Sandhya Gardner, Chief Medical Officer at HealthEdge. Dr. Gardner facilitated a discussion between clinicians from three large regional health plans, who shared how they address health equity among their member populations using digital solutions.
This discussion underscored the benefits of offering digital health management tools to members and care managers. For care managers, integrated digital health tools help improve staff efficiency and make it easier for care managers to identify health equity challenges and social determinants of health. The insights care teams get from digital health solutions enables them to deliver more timely and relevant care that meets members where they are. Digital health tools can also improve the accessibility of healthcare services by giving members a single point of access where they can reach out to care teams, read relevant health and benefits information, and keep track of their health goals.
“What we’re really concerned about are the folks who are working but unavailable to us. They may be shift workers, they may be working overnight, or beyond the hours our regular care managers work. They may have a burner cell phone. All those things lead to disparities. So figuring out ways to reach people through other channels, whatever they may be, is critical to reducing disparities.”
-Vice President of Clinical Operations, Regional Health Plan
Combat Industry Pressure with Integrated Care Management
Healthcare payers are under a lot of pressure—trying to combat rising costs, satisfy regulatory requirements, and increase member satisfaction while trying to stay competitive. In a session with two statewide health plan executives, panelists discussed the role of integrated care management in empowering key member, care team, and health plan stakeholders to achieve their goals. The fusion of digital member engagement and hands-on care management empowers members to take control of their health and make more informed decisions.
Attendees were given an exclusive look into the ways connected care ecosystems enhance operational capacities and forge a more empathetic, responsive culture. A digitally enabled care management approach is particularly beneficial for high-risk populations, like maternity and Medicaid. Plus, demonstrations of the Care-Wellframe solution provided concrete examples of how this technology can be seamlessly integrated into existing workflows, offering a glimpse into a future where healthcare is both high-tech and high-touch.
“Instead of asking our staff to take on the additional cognitive burden of choosing which members to call, we can clearly identify exactly who the members are who have emerging risks. It also gives our members access to a repository of information that they can access 24/7, 365.”
-Chief Medical Officer, Regional Health Plan
Championing Change Management: Best Practices
In a rapidly evolving healthcare landscape, adaptability is key. In one session, leaders from three regional and national payers shared best practices based on their experience with change management throughout the digital implementation process. Earning buy-in from stakeholders and future users can be a challenge. One way to improve adoption and reduce pushback is to build trust with your internal team through transparent communication and early involvement.
Panelists also emphasized the importance of cultivating a company culture that not only adapts to digital innovations but thrives because of them. From workflow optimization to team engagement, the health plan leaders provided a comprehensive toolkit to support successful digital transitions. Most notably, this included the importance of transparency throughout the implementation process. When stakeholders and employees know the “why” behind a change, they’re more likely to feel involved in the solution.
“Once you have team members that understand the value of ‘why,’ and over-communicating the value of ‘why’ so it’s not just sitting with the clinical team, that’s how you gain some traction.”
-Chief Medical Officer, National Health Plan
Leveraging AI for Care Management
Discussions about the applications of AI are everywhere. But where can it have the greatest impact on health plan operations? Many AI solutions need more training before they can fully replace manual documentation. But digital health management platforms like GuidingCare® and Wellframe leverage AI algorithms to improve clinical decision-making and member outcomes.
An AI assistant helps improve staff productivity by suggesting message templates, flagging high-risk members, making engagement recommendations, and suggesting next best actions. HealthEdge views AI as a key component of helping our customers become digital payers through transformational consumer experiences and business agility enablement.
“What are you actually trying to use this technology to solve for? Are you trying to save people time, generate insights, proactively take something that took a lot of manual effort and uplevel their skills to work top-of-license? Those are all areas we think are core-value oriented.”
-SVP of Product Management, HealthEdge®
Looking Forward
The 2024 Clinical Leadership Forum was a testament to the power of collective insight and a shared commitment across the healthcare sector to drive positive change. The discussions and solution demonstrations highlighted not only the current capabilities of digital care management, but the possibilities for future innovations.
For health plan executives and healthcare leaders, the forum served as both a call to action and a way to build relationships with leaders at similar organizations. The Clinical Leadership Forum was a powerful reminder that the future we aspire to is not just a possibility but an inevitability if we continue to innovate, collaborate, and lead with empathy and vision.
Learn more about HealthEdge® digital health management and member engagement solutions, visit the GuidingCare® and Wellframe pages on our website.
To stay ahead in the constantly evolving healthcare sector, payers are adopting digital solutions that put automation and accuracy at the core of every workflow. It’s critical that your Core Administrative Processing System (CAPS) delivers the most up-to-date data available so you can improve automation rates and streamline processes. Our five-part blog series, titled HealthRules® Payer Horizons, demonstrates how our CAPS solution empowers payers to adapt to meet new market opportunities.
Take advantage of end-to-end automation with HealthRules® Payer
In today’s healthcare landscape, the pressure to reduce costs and simultaneously enhance operational efficiency is more intense than ever for health plan leaders. Amidst this complex industry, automation emerges not just as a solution but as a strategic imperative for health plans seeking to invest in. HealthRules Payer is a platform uniquely designed to leverage the power of end-to-end automation to streamline operations and improve efficiency.
By harnessing the automation capabilities of HealthRules Payer, health plans can dramatically reduce administrative burden, streamline redundant processes, and optimize resource utilization. Equally critical is maintaining regulatory compliance in a strict and shifting environment. Through regular, automated updates, HealthRules Payer ensures that health plans remain compliant—significantly mitigating the risk of costly resubmissions.
Leveraging advanced automation will also let your plan reallocate manual resources toward higher-value work.
For health plan executives, the message is clear: leveraging end-to-end automation with HealthRules Payer not only addresses the immediate challenge of cost pressures but also unlocks the potential for strategic growth and sustainability.
1. Improve operational efficiency
Streamline workflows and create efficiencies by automating the claims adjudication process and saving manual reviews for what matters most. With HealthRules Payer, our health plan partners regularly achieve auto-adjudication rates over 90%, and claims accuracy of 99%.
96% increase in auto-adjudication rate for Medicare claims processing
95% decrease in pending claims
0 claims aged over 15 days on a monthly basis
2. Increase productivity and transparency
By automating more of the claims review process, your health plan can reduce complexities and administrative burdens associated with manual reviews. Plus, the HealthRules Payer platform is regularly updated with the latest payment regulations to reduce repayments and adjustments—saving time and money. For one customer, automating key processes led to savings of more than $1.6M.
3. Leverage auto reprocessing capabilities
The HealthRules Manager feature within HealthRules Payer allows your health plan to make adjustments based on your specific criteria to reduce reprocessing times. HealthRules Manager also allows users to manage membership, providers, billing and commissions, pricing, cost estimators, pricing transparency, and integrations with care and utilization management tools.
4. Support remote operations with hyper-automation
Accelerate payment accuracy and advanced configurations with integrated end-to-end system automation—what we call hyper-automation. By bringing disparate systems together and controlling information processing this way, your health plan can adapt more easily to industry demands and shifting payment guidelines. HealthRules Payer can integrate with your existing technology suite, as well as HealthEdge Source™ for payment integrity, GuidingCare® for care management, and Wellframe for member engagement.
Do you want to learn more about how HealthRules Payer can lower production time, reduce errors, and easily build audits across claims environments?
HealthEdge’s Regulatory Compliance Manager Maggie Brown and VP of Sales Solutions Diane Pascot recently addressed a large audience of AHIP members on an AHIP webinar that focused specifically on the rapidly evolving regulations surrounding price transparency. The two industry veterans gave attendees a fresh perspective on the evolution of multiple regulations as well as practical guidance on what payers can do in 2024 to better navigate the changing CMS regulations as they come into sharp focus this year for many payers, including the more than 130 HealthEdge customers.
This blog serves as a summary of the webinar. To listen to the full webinar, visit the HealthEdge Resources section on the HealthEdge website.
The rapidly evolving regulations can feel like a complex puzzle for many health plan leaders. But when you step back and look at the evolution of healthcare policy as a whole, it starts to make a bit more sense. The big picture is all about seeking transparency in healthcare processes and pricing, consumer protection, digital access to information and care, and the different regulations tend to build upon each other.
While these regulations tend to build upon each other, everything is constantly evolving so health plans can no longer respond to individual rules just in time. They must understand where the policies are going and be prepared with the right technology and partners who can help them implement strategies that will support compliance long term.
What We Know: Regulatory Evolution
As regulations continue to be finalized, they seem overwhelming, but they are designed to build on one another, giving payers opportunity to leverage a stepped approach. If we approach them as building upon each other, leaving room for unexpected regulations, it optimizes the ability to successfully prepare, taking one step at a time.
4 Concrete Steps Plans Can Take Today to Ensure Readiness
Concrete Step #1: Make sure you have the right technology, especially the right core administrative processing system (CAPS) in place and are focused on the right functions for existing and future rulings and implementation guidelines.
Your CAPS technology needs to have the structure that can pull together the right pieces of administrative data and the flexibility to support compliance as guidelines evolve. For example, with the new interoperability regulations, health plans will eventually have to show how many times each patient uses an access API in a year.
To achieve compliance with this reporting requirement, you need to start with a CAPS and a technology partner that can help you thoughtfully set up the access and structure to gather the meaningful data about individual and aggregated patient access. This must be done in a way that can be configured for any required audience or requirement.
1. Benefits administration and member management
Ensuringmembers are associated with the right benefits package
Properly tracking member accumulators so cost-sharing information is accurate and up-to-date
2. Provider network configuration and management
Seeking negotiated rates with all providers
Establishing processes for out-of-network providers so members aren’t surprised
Maintaining up to date provider directories with complete and accurate information
3. Billing and Data
Automated billing practices to ensure that members are held harmless under NSA criteria
Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) application programming interfaces (APIs) to improve the electronic exchange of health care data and streamline prior authorization processes
Cost-sharing data for all items and services available online
4. Claims Processing
Processes to avoid, and handle provider disputes
Processes that build on existing claims workflows, but can generate claims information for AEOBs for members – without triggering a bill or a payment
Compliance can get a bad reputation, because the regulations and changes can lead to burdensome manualized processes. In fact, many CAPS systems require payers to pend claims. But, when you leverage flexibility and configurability within the right structures, you can retain automated processes, minimize pending, pay your providers on time, and remain compliant. Well thought out reporting and analytics can be used to monitor trends, identify trends, reduce access to care issues and ultimately improve outcomes.
Concrete Plan #2: Web-based Price Comparison Tool
According to the No Surprises Act that builds on the Transparency in Coverage Act, health plans must provide web-based and personalized cost information, allowing members to compare prices for different providers and find out what their cost-sharing responsibility will be with respect to current accumulators.
Your CAPS system should have some kind of flexible claims functionality. With HealthRules® Payer, for example, plans can call for current accurate data into basically a ‘practice’ claim without triggering an adjudication.
This is a big deal, because in most claims processes, going through the process of pulling provider and member data together would automatically trigger a payment process. And, if plans try to work-around NOT using the claims system, they can’t get the same level of up-to-date accuracy. This is important because not only does provider pricing change, but member accumulators change every time they contribute to their deductible or out of pocket max.
While the regulations relating to this requirement were passed quite a while ago, just last month, in February, more detail was released.
This is another example of how plans can take a phased approach for evolving regulations by establishing and auditing this type of a tool also gives a good opportunity to see if there are any billing/benefits changes needed for your plan to meet parity guidelines, i.e., mental health co-pays are equivalent to physical health.
Similarly, interoperability and the prior authorization enhancements will rely not only on accurate data, but the ability to assemble the data into a meaningful story.
Price Transparency Snapshot
Challenge: Provide a web-based service for members to compare pricing for specific providers with respect to their current plan and accumulators
Solution: A CAPS system with flexible claims functionality will help health plans produce accurate claim adjudication details that include member responsibilities regarding:
Provider-specific payment/contract terms and fee schedules
Member benefit plan data
Member cost sharing based on accumulators at the time of trial claim adjudication
With the right technology, health plans can aggregate member-specific, provider, and service details according to accurate (not estimated) claims data. There is also CAPS technology available to connect this data to web-based member tools (e.g., member portals) so members can access cost information at any time and platforms through which customer service representatives can provide member-specific price comparisons to support member price comparison questions via phone.
Concrete Step #3: Advanced Explanations of Benefits (AEOB)
The Advanced Explanations of Benefits (AEOB), a key requirement introduced by the Consolidate Appropriations Act of 2021, is still pending. Guidelines are in development, with an RFI concluding last year. The AEOB will be triggered when a provider notifies the health plan that services have been scheduled, using a good faith estimate. Health plans must be able to respond with cost sharing based on that good faith estimate, which will include estimates from all providers involved in the scheduled service or procedure.
Payers need to make sure their CAPS system is prepared to meet regulations using a trial feature merged with existing EOB processes. The key piece here, again, is that they can use existing platform functionality and up-to-date, accurate information without triggering a payment.
If the scheduled service is with an out-of-network provider or facility, the EOB will note that and use qualified payment amounts to provide the anticipated cost. Plans may also have to recommend an in-network alternative to members on the AEOB.
AEOB Snapshot
Challenge: Prepare to meet AEOB requirements according to forthcoming rulemaking and implementation guidelines
Solution: A CAPS system with flexible claims functionality will help health plans aggregate details related to service codes and provider types, including:
Individual services costs
Episodes of care costs
Individual member-level details, including current accumulator data
With the right technology, health plans can generate anticipated claims payment detail in advance of a scheduled service. A full claims adjudication process takes advantage of all configuration details, calculating accurate – and not estimated – costs without triggering a payment.
Existing CAPS features generate EOBs for configurable and automated distribution that can be combined with the detail generated by the trial claim.
Concrete Step #4: Payer to Payer Data Exchange
Health plans using HealthRules Payer already meet the required relevant standards for this regulation, including:
United States Core Data for Interoperability (USCDI)
HL7® Fast Healthcare Interoperability Resources (FHIR®) Release 4.0.1
HL7 FHIR US Core Implementation Guide (IG) Standard for Trial Use (STU) 3.1.1
FHIR Bulk Data Access (Flat FHIR) (v1.0.0: STU 1)
OpenID Connect Core 1.0
Because we focus on regulation all day every day, we are also prepared with recommended implementation guidelines, such as:
HL7 FHIR CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®) IG Version STU 2.0.0
HL7 SMART App Launch IG Release 2.0.0 to support Backend Services Authorization
These implementation guidelines will also help health plans prepare for the upcoming prior authorization, such as:
HL7 FHIR Da Vinci Documentation Templates and Rules (DTR) IG Version STU 2.0.0
HL7 FHIR Da Vinci Prior Authorization Support (PAS) IG Version STU 2.0.1
Payer to Payer Data Exchange
Challenge: Payer to Payer Data Exchange has been expanded. The original set of requirements were deferred, and now there are structure and implementation guides for January 2027. This criteria includes HL7 and specific implementation guides.
Solution: A CAPS system and technical partner with the expertise to apply implementation guides for meaningful results
Leverages existing technology for new Payer to Payer Data Exchange meeting Required Standards with the expertise to recommend the right implementation guidelines
Creates meaningful information by sending and receiving the right data elements in the right configuration to ensure transparency and continuity of care for members
Key Takeaways
Regulations require us to understand the compliance requirements and the intention of each rule, how it relates to the current state of the business process, and how it impacts both the upstream and downstream processes. Each rule dives into the “why,” and health plans should seek to collaborate with technology partners to create solutions that support the requirement.
New regulations build on recently passed regulations; a stepped approach will help payers stay on top of the evolution. Stay on top of all types of communication such as changing enforcement dates, FAQs, guidelines, etc., not just final rulings.
Cost transparency and the proposed mental health parity regulations build toward consumer protections and updated data exchange methods. Make sure you have the data and analytics established to report on pricing for the Parity regulations. Be sure to pull your reports well in advance of the January 2025 enforcement date so you can identify and adjust any non-compliant pricing issues.
The right CAPS will have the structure and configurability that help health plans prepare for and adapt to ever-evolving regulations. Make sure you have the right CAPS technology and are focused on the right functions for existing and future rulings and implementation guidelines. Your CAPS needs to have the structure that can pull together the right pieces of administrative data and the flexibility to support compliance as guidelines evolve. Plans will not be able to meet the evolving regulations without technology that can ensure compliance and automation.
Keep the big picture in mind and look for the next-best step that works for your health plan. Make sure your CAPS technology meets required standards for upcoming interoperability and prior authorization regulations. Ensure you have a good technology partner who can help you start to plan your implementation guidelines and start planning now.
To learn more about how HealthEdge solutions can help your organization navigate the evolving CMS regulations, visit www.healthedge.com.
