A Robust Solution to the Interoperability and Patient Access Challenges of CMS Rule 9115-F
Meeting the requirements of the Centers for Medicare and Medicaid Services (CMS) Interoperability and Patient Access final rule (9115-F) can be a challenge, especially for payers. Although the rules are final, CMS is still issuing guidance on implementation. And payers have little experience with use of the HL7® FHIR® standard for information exchange, or with clinical data. The InterSystems HealthShare® CMS Solution Pack™ provides a simplified way to meet the final rule requirements for payers, supporting the rule’s use cases for 2021:
- Patient Access APIs – Giving patients access to their own claims, clinical, and pharmacy benefit information (2021)
- Provider Directory API – Online provider and pharmacy directory access (2021)
Introducing the HealthShare CMS Solution Pack
The HealthShare CMS Solution Pack provides an efficient means to access required claims, clinical, and pharmacy benefit data, regardless of its format, and transform it into FHIR 4.0.1 representations. Third-party applications using FHIR application programming interfaces (APIs) provide access to this data.
For payers subject to the rule, the HealthShare CMS Solution Pack provides a turnkey solution to support the Patient Access APIs and Provider Directory. The Solution Pack is based on the implementation guides referenced in the final rules and includes a FHIR 4.0.1. gateway, full support for version 1.0 clinical data set, and the required privacy and security standards.
Deployment
Provisioned in your cloud, on premise, or as a managed service, a HealthShare CMS Solution Pack deployment includes InterSystems implementation services to get you up and running with minimal burden on your IT staff. The solution currently is available for use by customers in the United States only.
Customer Support
When you select InterSystems HealthShare CMS Solution Pack you get more than technology. You also get our acclaimed customer support. Our best people are on the front lines 24/7. Every one of our customers gets help from somebody who really cares, immediately, without having to go through layers of people or process.
Use Cases
Patient Access APIs
The power of the FHIR standard is a simple, web-like method of data access and updating. The power of the HealthShare CMS Solution Pack is its scalability plus advanced data aggregation, transformation, and normalization capabilities. It enables you to deliver up-to-date, clean, and reliable information via HL7 FHIR 4.0.1, regardless of the data’s original source or format.
Claims Data Mapping
InterSystems HealthShare CMS Solution Pack ingests administrative data including claims, encounters with capitated providers, provider remittances, and enrollee cost-sharing into the HealthShare database, and exposes it based on HL7 FHIR 4.0.1 using the CARIN Alliance Blue Button 2.0 implementation guide.
Clinical Data Mapping
InterSystems HealthShare CMS Solution Pack also covers clinical data mapping to USCDI v1 data types based on FHIR US Core. It provides accurate and trustworthy information to members through its data aggregation, normalization, and de-duplication processes.
Pharmacy Benefit Data
For Medicare Advantage Plans with a Part D benefit, and Medicaid plans, InterSystems HealthShare CMS Solution Pack ingests the appropriate data from the health plan and exposes it through FHIR 4.0 APIs based on the Da Vinci PDeX:Formulary implementation guide.
Authorization and Authentication
The solution supports the required SMART IG/OAuth 2.0 standards for authorization, which permit third-party apps to access FHIR resources. It then verifies the end-user identity via OpenID Connect and uses that authentication to retrieve the resources.
Identity Management
Many payers don’t have a single unique ID for their members. Once you add in clinical data, it’s critical that all of the data is mapped to one unique member identifier. Powered by the proven InterSystems Enterprise Master Patient Index (EMPI), the CMS Solution Pack provides identity management to match member data from multiple source systems, creating a unified longitudinal care record.
Member Consent Management
Health plan members and others can choose to allow or deny access to all of their information, as required by 9115-F. More granular access control is available as an additional purchase.
Provider Directory API
InterSystems HealthShare CMS Solution Pack transforms your provider directory data to FHIR, including plan, names, network status, addresses, phone numbers and specialties, as well as pharmacy directory data for Medicare Advantage and Medicaid Plans. The necessary publicly available provider directory API is part of the solution. Our Da-Vinci PDEX Plan-Net FHIR APIs make the detailed care landscape of provider and pharmacy directory information accessible via FHIR APIs as required by the rule.
HealthShare Provides Solutions Beyond CMS 9115-F
InterSystems HealthShare CMS Solution Pack provides a path to address broader use cases using our full InterSystems HealthShare product suite. For payers, InterSystems HealthShare provides the data and analytics required to support use cases such as HEDIS reporting and Risk Adjustment. For providers, use cases include value-based care, population management, and COVID-19 dashboards.
Learn More
Find more information about: