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Interoperability: Digitally Connecting Members, Providers and Payers

Date: 06/25/21

Interoperability seeks to remove data barriers and silos within the health-care industry, connecting people with the information and tools they need to make informed decisions about their health. In March 2020, the Centers for Medicare and Medicaid Services (CMS) finalized its Interoperability and Patient Access Rule (CMS-9115-F), which aims to enhance control for a Superior HealthPlan member to access and obtain their health-care information. This was published alongside the Cures Act Final Rule from the Texas Health and Human Services (HHS) Office of the National Coordinator for Health Information Technology (ONC), which establishes further standards around interoperability practices.

Interoperability will be a long-term, strategic transformation of our industry, focused on operational efficiencies, higher quality medical care and improved health outcomes. By ensuring that payers and providers are using common data formats and applications, the Interoperability Rule will allow member health information to be shared quickly and easily via third party applications that can be downloaded on a member’s phone. Through these digital enhancements, Superior HealthPlan will be able to improve collaboration with our members, provider networks, government entities and other payers.

What This Means for Providers

Having patient medical information and history in one place helps providers better understand members’ health so they can make informed care decisions and improve health outcomes. Access to this information will also improve partnership and care coordination between providers and payers.

The Interoperability Rules have three main areas of focus for providers to ensure they are properly supporting digital member access to healthcare information. These include:

  • Information Blocking Prevention: Providers will need to have policies and procedures in place to ensure information blocking practices are prevented. These include any practices that interfere with the access, exchange or use of Electronic Health Information (EHI).
  • Up-to-Date Digital Provider Information: CMS will now require all individual health-care providers and facilities to take immediate action to update their National Plan and Provider Enumeration System (NPPES) records online to add digital contact information. Providers should work with their Electronic Health Record (EHR) vendors to ensure up-to-date digital information and current National Provider Identifier (NPI) is routinely updated.
  • COP Compliance: The Interoperability Rule introduces a new Medicare Condition of Participation (COP) that requires all hospitals to send electronic notifications to a member’s health-care providers (i.e. Primary Care Provider [PCP]) upon the member’s Admission, Discharge or Transfer (ADT).

How Superior Supports Interoperability

  • Beginning July 1, Superior will offer a secure, standards-based Application Programming Interface (API) to allow members to easily access their own health-care information – including claims, medical history, lab results and more – through a third-party app of their choice.
  • Superior members will also have access to their own EHR, privacy and security educational resources.
  • Superior’s provider directory information will be made publically available via our API. This will help members and providers alike to use third-party apps to connect with other providers for care coordination.
  • Superior has built secure processes for data exchange with other payers that aligns with the ONC rule’s technical standards.

Interoperability Resources and Guidance

  • CARIN Alliance
    • The CARIN alliance is a bipartisan, multi-sector collaborative working to advance consumer-directed exchange of health information. Learn more about third-party application privacy standards at www.carinalliance.com.
    • The CARIN Code of Conduct is a set of industry-leading best practices these applications have voluntarily adopted to protect and secure member health information. It requires third-party application developers to prove they will follow certain privacy standards through attestation. Visit myhealthapplication.com/health-apps/connections/Carin for a list of apps that have attested to the CARIN Code of Conduct.
  • Fast Healthcare Interoperability Resources® (FHIR)
    • FHIR is a Health Level Seven International (HL7®) standard for exchanging health-care information electronically. It is the next generation exchange framework being adopted by the health-care community to advance interoperability. Education and resources can be found at ecqi.healthit.gov.
  • CMS and ONC

For additional information, please contact Superior Provider Services:

  • Ambetter from Superior HealthPlan: 1-877-687-1196
  • Allwell from Superior HealthPlan (HMO and HMO SNP), CHIP, Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and STAR+PLUS MMP: 1-877-391-5921