Cures Act - Payer Solutions

The 21st Century Cures Act (“Cures Act”) was passed by Congress and signed into law in December 2016. The bill authorized $6.3 Billion in funding to be directed primarily to the National Institutes of Health (NIH) for a handful of different initiatives around population health. 

CMS Rule 9115-F delivers on the Administration’s promise to put patients first, giving them access to their health information when they need it most and in a way they can best use it. As part of the Trump Administration’s MyHealthEData initiative, this final rule is focused on driving interoperability and patient access to health information by liberating patient data using CMS authority to regulate Medicare Advantage (MA), Medicaid, CHIP, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs). CMS recently introduced new interoperability mandates for health plans (MA organizations, Medicaid FFS programs, CHIP FFS programs, Medicaid managed care plans, and CHIP managed care entities) based on the regulations of the Cures Act that must be implemented by July 1, 2021.

What it means for Payers?

Payers, or insurance companies, need to focus on two key challenge areas:

Patient Access
  • Implement and maintain a secure, standards-based Patient Access API (using Health Level 7® (HL7) Fast Healthcare Interoperability Resources® (FHIR) 4.0.1) that allows patients to easily access their claims and encounter information
Data Interoperability
  • Make the provider directory information available via the “Provider Directory API” using a public-facing digital endpoint on the payer’s website
  • Part D Medicare Advantage plans must also make formulary information available via the Patient Access API
  • Payer to Payer Data Exchange to share claims and clinical data using the FHIR® R4 standard
CURES Act - Payer Solutions

314e’s 21st Century Cures Act solutions can help you build customized solutions on top of its state-of-the-art Muspell CDR that integrates with your existing IT system so you are ready to face these challenges. Here is how 314e can help you in each challenge area:

Challenge: Patient Access APIs
As a Health plan you need to implement and maintain a secure, standards-based Patient Access API (using Health Level 7® (HL7) Fast Healthcare Interoperability Resources® (FHIR) 4.0.1) that allows patients to easily access their claims and encounter information, including cost, as well as a defined subset of their clinical information through third-party applications of their choice.
Compliance Deadline

July 1st, 2021

314e's Solution
314e’s Muspell FHIR Suite can be used to design your FHIR® API endpoint which will extract clinical and financial information for the member from payer systems using X12 EDI, CCD, and other proprietary formats, convert them to FHIR and then provide the required information to third-party apps.We will design this end-to-end in a highly scalable manner.
Challenge: Provider Directory API
As a Health plan you must make available a FHIR® API based list of providers that are in-network via a public-facing digital endpoint on the payer’s website. Provider directory updates must be available via API within 30 days of receipt of new data or changes to directory data. Key data elements required for this are Provider names and network status, addresses, Phone numbers, Specialties.
Compliance Deadline

July 1st, 2021

314e's Solution
314e’s Muspell FHIR® Suite can be used to  design FHIR® API endpoint which will extract payer network information (Provider names and network status, addresses, Phone numbers, Specialties) from your payer network management software systems, convert to FHIR® and then provide the information to an endpoint which could be made available on the payer’s website.This will be done in a manner that has minimum impact on your existing IT infrastructure and team
Challenge: Payer to Payer Data Exchange

Payers are required to exchange patient data at the member’s request so members can take all their data with them as they move between payers 

Key data elements required for this are Clinical data specified under U.S. Core Data for Interoperability (USCDI) version 1.

Compliance Deadline

July 1st, 2022

314e's Solution
314e’s Muspell FHIR® Suite can provide FHIR® API endpoint which will extract clinical and financial information for the member from payer systems using X12 EDI, CCD, and other proprietary formats, etc., convert to FHIR® and then provide the required information to third-party apps.

In addition to these specific solutions, 314e’s experienced team can provide you Application Development & Maintenance, Analytics and Staff Augmentation solutions for your 21st Century CURES Act compliance needs.

 

Contact us for more information

Menu