Menu
An overview of how Payer to Payer Exchange fits into the CMS Interoperability and Patient Access Rule and its potential to improve the healthcare industry by enabling seamless transfer of patient health records between healthcare plans.
In this video, we’ll discuss the key challenges associated with Payer to Payer Exchange that everyone in the industry is grappling with. These challenges include validating and verifying the identity of other payers in the digital age and discovering FHIR API endpoints of other payers in order to access the required data.
Here on this clip we’ll explore the benefits of implementing Payer to Payer Exchange, which include delivering better care more efficiently. By having access to a member’s past health history, healthcare providers can better understand their health challenges and deliver proactive care management. This, in turn, can help align members’ needs with preventative services, ultimately reducing the cost of high-level care.
This video discusses CMS’s interoperability rule and its requirement for regulated plans to maintain an API for sharing data with members. Plans impacted include Medicare Advantage, Medicaid Managed Care, Children’s Health Insurance Program, and qualified health plans on the federal exchange. Although enforcement is not yet in effect, healthcare providers should prepare for payer to payer exchange to comply with future rulemaking expected by 2023. A notice of proposed rulemaking is expected soon, clarifying the full impact of this regulation.
This video covers the compliance deadlines for Payer to Payer Exchange provision of the CMS interoperability and patient access rule. It explains which plans are impacted and when compliance is expected to be required. The notice for proposed rulemaking is expected to drop soon and compliance is expected to be required in 2023.
This video discusses the consequences for plans that don’t comply with the payer to payer provision of the CMS interoperability and patient access rule. While there are currently no penalties, plans need to be prepared as enforcement may begin soon. Plans impacted include Medicare Advantage, Medicaid, children’s health insurance programs, and qualified health plans on the federally facilitated exchange. A notice of proposed rulemaking is expected in early 2022, and compliance is anticipated in 2023.
Learn about five best practices for Payer-to-Payer Exchange to bring strategic benefits to your organization. These practices include building trust with members, leveraging retrieved data, integrating data into member management programs, improving financials, and proactively managing new members’ health. Explore more ways to maximize P2P exchange for your organization by visiting payertopayer.com
The video discusses the payer-to-payer exchange choices for health plans, which is part of the CMS interoperability and patient access rule. There are three options: provide a service to members that connects to other players’ APIs, partner with an organization that offers that service, or implement a business-to-business flow. The third option focuses on testing out these flows to simplify the process for members.
Learn about how health plans can implement Payer-to-Payer exchange using FHIR-based exchange methods recommended by CMS. There are two methods: member-mediated exchange that uses the patient access API and member-directed exchange, where authorization is obtained in advance. Member-mediated exchange can be done today, while member-directed exchange is being actively tested. Further details can be found at payertopayer.com
The video discusses using the Patient Access API for Payer-to-Payer exchange and the challenges associated with it. The first challenge is identifying another payer as there is no national identifier. The second is discovering FHIR endpoints for other payers. The third challenge is building trust with members and encouraging them to transfer data. The fourth is using prior plan credentials. Onyx Health offers a service called payertopayer.com to help address these challenges.
Learn about Bulk Payer-To-Payer Exchange exchange which is an automated process designed to share data between payers. It requires consent from the member and allows the use of standard restful APIs. This is particularly useful when there is a lot of clinical data involved. For more information, visit payertopayer.com.
Prior authorization is a pre-approval process where a provider seeks approval from a health plan to initiate a treatment plan or approve a drug for a patient. It involves multiple stakeholders and communication between the provider and the payer, which can result in delays. Balaji Narayanan, VP of Engineering and Product Development at Onyx, explains the process in this video.
This video talks about electronic prior authorization (ePA), a modern solution to the current prior authorization process, where data is transmitted electronically between providers and payers to get approval in a digitized format. The CMS is releasing regulations to standardize the process, reducing complexity, manpower, and manual activity. The implementation guide developed by HL7 is available publicly for anyone who wants to implement ePA.
In this video learn about the challenges with the existing prior authorization process in this video. The lack of standardization across different payers, the time-consuming nature of the process, the need for extensive documentation, and the confusion for patients all add to the complexity. Providers and pharmacists may not be aware of the need for prior authorization until claims are denied. These challenges burden patients, providers, and payers and highlight the need for a modern solution like ePA.
The video is about the current status of Electronic Prior Authorization (ePA) in the healthcare industry. It explains how ePA is being explored by many health plans to improve patients’ health benefits and reduce costs in the prior authorization process. The industry is developing ePA with the help of EMR systems, vendors, and payers invested in HL7 fire standards. Work is being coordinated by HL7 through several reference implementations and connector processes to improve the implementation guides.
Learn about the benefits of Electronic Prior Authorization (EPA) in healthcare. The American Medical Association found that delays in prior authorization can lead to serious health problems, including hospitalizations. EPA reduces burden for all stakeholders and can avoid time-consuming manual reviews. EPA provides real-time approval and reduces costs for both payers and providers. Benefits include reducing the burden of documentation, faster decision-making, better results, and better treatment plans for patients
The video explains the first component of Electronic Prior Authorization called “Coverage Requirements Discovery (CRD).” CRD is a standard method for providers to check with payers to see if prior authorization is required for a treatment, service, or drug. The CRD implementation guide provides a way to integrate prior authorization queries into the EMR or EHR system, and it defines the information required to determine the decision to approve a prior authorization.
This video explains Component 2 of the Electronic Prior Authorization process, which focuses on the documentation template and rules. It defines the specific documents and rules that providers must submit for payers to approve or reject prior authorization requests. The implementation guide standardizes the process across all payer-provider submissions and reduces the provider’s burden by automatically extracting information from the provider’s system.
This video discusses the final step of the electronic prior authorization process called Prior Authorization Support (PAS). The provider submits all documentation and questionnaire responses in a bundle to the payer for a decision. The payer may obtain a waiver to receive the documentation in a different format, but must prove their success rate. If the payer cannot make a decision, the status may be pended for further review.
This video discusses the technical requirements for implementing electronic prior authorization (ePA) for payers. This includes having an identity service that is compliant with the SMART on FHIR technology, integrating with the providers’ system, having a FIRE server for storing structured resources, technical skills in CVS and CDS Hooks technologies, and whitelisting providers that don’t require prior authorization. Additionally, the payer needs a medical policy guideline that needs to be converted to a SQL library and a questionnaire generator.
This video discusses how Onyx, a SAS solution provider, can help payers comply with mandates and implement electronic prior authorization. Onyx has accelerators that can expedite development and is built with Microsoft, providing extensible support for multiple implementation sites. Their framework enables rapid customization and compliance with HL 7 Davinci standards. The viewer is encouraged to contact Onyx’s client success team for assistance with their FHIR needs.
This video highlights the key takeaways from HL7 FHIR Connectathon 33 by Onyx, a leader in fire interoperability. It covers the latest developments in FHIR implementation, including SMART on FHIR, Da Vinci, and more. Watch this video to learn how Onyx is helping healthcare organizations with their FHIR needs.
Onyx Health demonstrates participation in HL7 Da Vinci Payer Data Exchange (PDex) project at Connectathon33
Introducing MoveMyHealthData, which enables you to connect with more than 300 previous payers in three easy steps and provides a straightforward, safe approach for you to take control of your medical data.
A comprehensive overview of the rule, including its key provisions and benefits. The CMS Interoperability Rule mandates health plans to provide members with an industry standard API based on HL7 FHIR. California now requires all commercial Health Plans in the state to offer Patient Access APIs by January 1, 2024.
