Skip to main content

Care Management Interoperability: FHIR and the HL7 Da Vinci Project at HealthEdge

In today’s rapidly changing healthcare environment, interoperability is central to health plan efforts to achieve better care, cost savings, and faster innovation. Adopting next-generation standards to harmonize health information and meet regulatory interoperability requirements is critical to successful care management for digital payers today. Modern, integrated technology systems unlock:

  • Efficient Care Coordination: Care management interoperability ensures smooth transitions between care settings, benefiting members and providers.
  • Improved Outcomes: Access to comprehensive healthcare data empowers care managers, leading to better decisions and healthier populations.
  • Reduced Costs: Streamlined administrative processes help optimize resources and mitigate costs for health plans.

That’s why HealthEdge® prioritizes care management interoperability in its integrated healthcare payer solutions. These solutions enable health plans to succeed in their digital transformation journeys, helping create a future where data flows freely, outcomes thrive, and the member experience is significantly improved throughout treatment lifecycles.

The Power of FHIR

FHIR (Fast Healthcare Interoperability Resources), developed by Health Level 7 (HL7), is a REST API-focused standard designed to simplify the exchange of health information between healthcare technologies. HealthEdge recognizes the critical role FHIR plays in enabling seamless data exchange and achieving member-centered care where the correct data is available at the right time for members, providers, and payers.

The HealthEdge GuidingCare® care management solution supports a variety of FHIR use cases today. By the end of 2024, it will support all new prior authorization requirements of the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), which alleviates the administrative burden of the authorization process. With CMS-0057-F, health plans have until January 1, 2027, to implement real-time APIs for the following transactions:

  • Coverage Requirement Discovery (CRD): The API must be populated with a list of items and services that require prior authorization.
  • Documentation Templates/Rules (DTR): The API must identify the payer’s documentation requirements for all items and services that require prior authorization.
  • Prior Authorization Support (PAS): The API must support creating and exchanging prior authorization requests from providers and responses from payers.

GuidingCare is well-positioned to help health plans comply with CMS-0057-F and ensure that they support modern requirements for payer-provider collaboration.

HealthEdge’s Role in the HL7® Da Vinci Project to Advance Interoperability

To accelerate the adoption of interoperability standards across the entire healthcare spectrum, HealthEdge is participating in the HL7 Da Vinci Project, a private sector initiative involving more than 50 industry-leading providers, payers, and technology vendors to advance (VBC) through seamless data exchange. More specifically, the project is focused on developing HL7 FHIR-compliant APIs as the standard for supporting and integrating VBC data exchange across healthcare communities. The initiative aims to help automate high-volume manual activities that can benefit from automation, identify critical data exposure, and improve processes at key points within workflows across healthcare partners—including care teams, vendors, and payers.

With the release of the CMS Interoperability and Prior Authorization Final Rule on January 17, 2024, there is heightened urgency among those participating in the Da Vinci Project. By being part of the project, HealthEdge and its customers will remain at the forefront of interoperability and the latest industry standards in the following ways:

Addressing Interoperability Challenges:

As health plans transition from outdated legacy solutions, they face challenges related to data standardization and easy information access. These issues hinder efficient care delivery solutions and effective care management models. By participating in the Da Vinci Project, HealthEdge will help drive standards that overcome these challenges and positively impact clinical outcomes, quality, cost, and care management for health plans.

Value-Based Care (VBC) Focus:

The Da Vinci Project aims to empower health plans to shift toward VBC. By leveraging HL7 FHIR, Da Vinci facilitates critical data exchange between payers and providers to accelerate patient-centered care. HL7 FHIR enables seamless payment and coverage data integration with care-related information. HealthEdge will be able to ensure its solutions, including GuidingCare, incorporate the latest standards supporting VBC.

Minimizing Unique Solutions:

Historically, health plans have developed unique solutions for value-based care delivery. Da Vinci seeks to reduce this fragmentation by promoting interoperability across all stakeholders. It provides common standards, implementation guides, and reference implementations to guide the national-scale adoption of VBC data exchange. HealthEdge will apply the latest knowledge to accelerate digital transformation for health plans.

Unlock the Future of Healthcare with HealthEdge

HealthEdge is committed to improving healthcare by actively supporting and integrating VBC data exchange, eliminating administrative burdens, and improving member experiences. As a leader in healthcare software, HealthEdge is working with the Da Vinci Project to ensure its solutions remain at the forefront of innovation in this critical domain. We are excited to be a part of this transformative journey and look forward to shaping the future of healthcare through FHIR interoperability compliance.

To learn more about how HealthEdge GuidingCare supports care management interoperability, read this whitepaper and visit