Deploy the Technology You Need to Meet Regulatory Requirements and Advance Larger Aims

Today’s health plan leaders all too often face a difficult balancing act: meeting pressing regulatory requirements while advancing larger organizational goals. With InterSystems® Payer Services, you don’t have to prioritize one aim over the other.

Our suite of regulatory solutions for health plans, called InterSystems Payer Services, is delivered as modular components that interface with the systems you already have in place, with each other, and with other InterSystems products like HealthShare® Unified Care Record for maximum flexibility. So, you can license just what your organization needs for compliance without slowing progress on your interoperability strategy. Our modular approach avoids needless tradeoffs, protects and extends previous investments, preserves flexibility, and maximizes your IT ROI.

InterSystems Payer Services not only enables compliance with recent regulatory mandates but readies your organization for further refinements and updates to the rules and guidelines governing interoperability. The CMS Interoperability and Prior Authorization Rule (CMS-0057-F) now commanding industry-wide investment is the next layer in an expanding regulatory framework driving API-based information sharing across healthcare, and the Da Vinci Implementation Guides cited in this rule continue to evolve. We know because InterSystems is a longstanding and active member of the HL7® Da Vinci Project as well as a host of other associations and initiatives informing healthcare policy.

As a private company, with no outside investors or debt, we are uniquely positioned to keep our focus where it belongs—on delivering value to our customers, including national, regional, and provider-sponsored plans. InterSystems has been a leader in healthcare data management and standards-based interoperability for decades, with a proven track record of continuously updating our products to support the latest standards and frameworks.

InterSystems Payer Services includes three principal components: ePrior Authorization, Clinical Data Exchange, and Payer Data Sharing. You can license the specific components that best fit your immediate needs and add other offerings from InterSystems Payer Services or our larger HealthShare suite whenever the time is right for your organization.

Each component of InterSystems Payer Services is available as a managed cloud service or an on-premises solution and is designed to integrate with your existing systems and other InterSystems products, like Unified Care Record, InterSystems EMPI™, and InterSystems Health Connect™. And if you already use the Unified Care Record, we will expand your existing license to include all InterSystems Payer Services components at no additional licensing cost.

CMS-0057, along with new state laws and industry initiatives, requires health plans to support electronic prior authorization (ePA) via FHIR APIs, speeding answers to whether prior authorization is needed, what documentation is required, and final determination. Our ePrior Authorization component meets this mandate by delivering and supporting a set of FHIR APIs prescribed by the three Da Vinci “burden reduction” Implementation Guides cited in the rule: Coverage Requirements Discovery (CRD); Documentation Templates and Rules (DTR); and Prior Authorization Support (PAS).

This component includes an HL7® FHIR® server, a FHIR repository, a CDS Hooks server, standard and adaptive formats for CQL questionnaires, FHIR-to-x12 mappings, subscription-based provider alerts, and performance tracking and reporting. Additionally, it readily pairs with InterSystems products and services for automating connectivity with both your utilization management systems and delegated vendors. It can also flow clinical data from prior authorization requests into Unified Care Record for use in care coordination, quality reporting, and value-based care.

Key to widespread provider adoption of ePA is the ability to submit supporting clinical documentation efficiently. Past efforts to automate prior authorization have struggled to gain traction in no small part due to limits on electronic attachments. To meet this need, InterSystems supplements ePrior Authorization with Clinical Data Exchange, a standardized process for sharing clinical data using FHIR. With this component, you can electronically request and receive from network providers targeted information that is beyond the scope of FHIR CQL questionnaires yet needed to assess more complicated prior authorization requests. Providers can also electronically submit unsolicited documentation relevant to each request.

Clinical Data Exchange adheres to the Da Vinci CDex Implementation Guide, including both FHIR API infrastructure and services. It can be deployed for multiple use cases like gathering supplementary clinical data for performance measurement, risk adjustment, and quality reporting.

CMS-0057 calls for health plan investment in payer data sharing with members, providers, and other plans via FHIR APIs. It requires impacted plans to update and expand their current Patient Access API to facilitate member-centric care and to add a Provider Access API and Payer-to-Payer API to promote care continuity.

InterSystems Payer Data Sharing enables plans to meet these mandates and advance their underlying aims by providing the required FHIR APIs and associated resources needed to deploy them. It includes solutions for matching members to members of prior and concurrent plans, attributing members to treating providers per the Da Vinci ATR Implementation Guide, processing bulk queries per the Da Vinci PDex Implementation Guide, and reporting API utilization.

Much of the information shared through the Provider Access and Payer-to-Payer APIs builds on data requirements for the Patient Access API. So, to maximize ROI, our Payer Data Sharing component is designed to build on a plan’s existing Patient Access API, regardless of whether it comes from InterSystems. Additionally, information received from another plan can automatically flow into our longitudinal health record, Unified Care Record. Without this linkage, plans may miss out on the most promising return on the regulation’s data sharing mandates. Most care management systems can’t integrate and act on FHIR bundles without data parsing and transformation.

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Disclaimer: InterSystems software, associated services, materials, and expertise may utilize artificial intelligence capability and functionality. Please refer to the InterSystems Transparency Notice, Product-specific Documentation and the applicable Statement of Intended Use for more information.