Health plans are under pressure to comply with the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) and deliver better digital experiences for members and providers. Standing up Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization interfaces at scale demands dependable plumbing, strong governance, and clear observability; it should not require rebuilding core infrastructure. InterSystems Payer Services™ lets you operationalize these capabilities on a modular platform while continuously building a governed longitudinal member health record to power care management, analytics, and reporting.

InterSystems Payer Services delivers all four APIs required by CMS-0057-F—Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization along with the supporting electronic prior authorization workflow services. Built on a high-performance, healthcare-native data platform, it facilitates predictable integrations with partner systems, with endpoints and payloads that align to HL7® FHIR® Release 4 and the HL7 Da Vinci Implementation Guides. The same foundation extends beyond regulation to support new digital services, ecosystem partnerships, and trusted data pipelines for your analytics and AI.

• Patient Access: Members securely access their information through third-party applications.
• Provider Access: Treating providers receive timely information that supports care coordination.
• Payer-to-Payer: Health plans exchange member information when coverage changes or overlaps.
• FHIR R4 APIs implemented per CMS-0057-F referenced IGs: HL7 Da Vinci, PDex (including Plan-Net and US Drug Formulary) and HL7 CARIN IG for Blue Button®. Requests are authenticated, consent is evaluated per request, and standard FHIR searches are supported—including date filters and bulk data export that adhere to scopes for each. Responses return profile validated, predictable resources.

• Coverage guidance, documentation capture, submission, tracking, and decisions implemented using the HL7 Da Vinci Coverage Requirements Discovery (CRD), Documentation Templates and Rules (DTR), and Prior Authorization Support (PAS) Implementation Guides.
• Coverage Requirements Discovery evaluates order context against coverage requirements; Documentation Templates and Rules guides collection of the exact clinical information; Prior Authorization Support submits and tracks requests, including bridging between FHIR and administrative transaction formats when needed. Decisions and reason information are captured, and timeliness metrics are surfaced to support regulatory expectations.
• Routing, transformation, and adapters are incorporated to support integration with existing applications.

Data received within ePrior Authorization EoBs are written to the full member record. Member identity is resolved, integrating with an enterprise master person index when present - and records are deduplicated, versioned, and indexed to create a reusable, trustworthy longitudinal member health record.

FHIR R4–based APIs, conformant with US Core profiles (supporting USCDI), the HL7 CARIN IG for Blue Button, and relevant HL7 Da Vinci implementation guides enable partners to connect using familiar profiles and operations and to validate once for repeatable use across providers, applications, and health plans.

Only the right people see the right information - identity is verified, access is limited by role and context, member consent is honored on every request, and a complete audit trail records who accessed what, when, and why - reducing risk, building trust, and simplifying audits.

Bulk and asynchronous processing for large data volumes; live observability for latency, throughput, error rates, and timeliness; policy-driven throttling and retries to sustain stability as implementation guides evolve.

• Shorter Prior-Authorization Cycles with reduced pend rates and clear, tracked timeliness against regulatory expectations.
• A Reusable, Trustworthy Longitudinal Health Record that powers care management, quality improvement, analytics, and reporting—without repeatedly rebuilding integrations.
• Lower Integration Cost and Faster Time to Production through standards alignment.
• Audit Readiness and Risk Reduction via per-request consent enforcement and comprehensive audit trails.
• Dependable Day-to-Day Operations and a future-ready foundation that protects total cost of ownership.

InterSystems Payer Services can be deployed on premises or as a fully managed service. When you subscribe to InterSystems Payer Services Managed Services, InterSystems designs, hosts, and delivers the integration platform, so you do not need to purchase, operate, secure, or maintain the infrastructure yourself.

InterSystems Payer Services Managed Services include:

• All data center resources, including hosting, hardware, and network capacity needed to run the solution
• Ongoing maintenance of all solution components
• Customer-specific configuration and implementation services to bring the solution live, including building connections
• 24/7 support for the solution including real-time monitoring
• Seamless upgrades
• Sophisticated security and data protection program

InterSystems Payer Services runs on InterSystems HealthShare® and the InterSystems IRIS® for Health data platform, and pairs naturally with:

• HealthShare Unified Care Record® - longitudinal health record for unified, real-time insight and better care.
• InterSystems EMPI™ - next-generation master person index with referential matching.
  

InterSystems Payer Services is backed by InterSystems acclaimed customer support and extensive educational resources. Our global support organization provides 24/7 assistance for production systems, with critical issue response within 15 minutes. We offer comprehensive training programs, online documentation, and certification courses to ensure your team can effectively implement and operate the platform. Search for Payer Services resources at learning.intersystems.com.

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