Payer
Healthcare Insurance Payer
Technology
Azure Health Data Services
Azure Logic Apps
Key Outcomes
Achieved CMS mandate compliance
Easier access to accurate provider information and personal health records
VNB Health assisted a leading healthcare payer in seamlessly integrating the Provider Directory and Patient Access API, ensuring secure data exchange and full compliance with the CMS mandate.
Customer Profile
The customer is a prominent healthcare insurance provider serving a vast population. With a rich history in the industry, they are committed to delivering comprehensive healthcare solutions and enhancing member experiences. The organization operates in a highly regulated environment, necessitating robust and compliant systems. Due to the sheer volume of transactions and complex nature of healthcare data, the customer handles a significant workload, demanding efficient and reliable IT operations.
Customer Situation
The customer handled 270/271 Healthcare Eligibility Benefit Inquiry transactions to verify patient healthcare eligibility, coverage, and benefits. The customer relied on custom API interfaces built on Microsoft BizTalk Server to connect with multiple insurance payers. This complex integration environment, characterized by high transaction volumes and frequent changes, was prone to instability. Updates to one payer’s interface often disrupted connections with others. To mitigate this risk, accelerate development and ease the build, deployment and testing process, the customer sought an automated solution that would enable continuous integration and continuous delivery (CI/CD) with robust automated testing.
Customer Profile
A leading health plan payer serving over 1.5 million members, the customer offers dental and vision insurance plans for individuals, employers, and government programs. Their expansive provider network is backed by dedicated local service teams in Iowa.
Customer Situation
With the CMS Interoperability and Patient Access Final Rule mandating the implementation of a Provider Directory and Patient Access API, the customer needed a reliable solution to achieve FHIR compliance for payers. Ensuring secure, seamless access to patient and provider data while meeting regulatory requirements was a top priority. However, integrating disparate systems and maintaining data security posed significant challenges.
VNB Solution
Upon analyzing the customer’s internal EHR system, VNB Health designed a solution aligned with CMS requirements for FHIR compliance for payers. The solution leveraged Microsoft Azure Health Data Services, Azure Logic Apps, and Azure SQL to ensure compliance with CMS mandates.
- EHR Integration & Data Synchronization: VNB utilized Azure Logic Apps to integrate with the EHR system. This enabled automated data exchange and real-time updates for the Provider Directory and Patient Access API. A secure repository in Azure SQL was also established to store structured patient data.
- Secure API Development: We developed Azure Logic Apps-based APIs, implementing OAuth 2.0 authentication to ensure secure and compliant access to patient and provider data.
- FHIR Data Management: By leveraging Azure Health Data Services, the solution ensured that patient and provider information adhered to FHIR standards. This enabled efficient interoperability and seamless regulatory adherence.
- Compliance & Standardization: VNB followed ONC’s 21st Century Cures Act final rule and CMS implementation guides for Claims, Encounter Data, and Provider Directory Data. These measures ensured full regulatory compliance.
Customer Benefits
By implementing this solution, the customer successfully met regulatory requirements while optimizing their data exchange processes. The solution provided additional benefits, including:
- Regulatory Readiness: The solution established a strong foundation for future interoperability requirements. This positioned the customer for ongoing compliance with evolving CMS mandates.
- Operational Efficiency: Automated data exchange reduced manual processes. As a result, accuracy improved, and internal resources were freed up for higher-value tasks.
- Enhanced Member Experience: Members gained easier access to accurate provider information and personal health records. This led to improved engagement and satisfaction.