The next wave of rules and regulations from CMS that lays down several compliance requirements for Health Plans will have massive implications on technology, workflow process, and business. The latest standards (FHIR and USCDI) and rules (Interoperability and Patient Access; Transparency in Coverage) are pushing health plans to relook at their IT landscape. While these compliances are challenging, they present an opportunity for health plans to piggyback on these changes to derive tangible business value.

Imminent Future

Health Plans are looking at quite a few new regulations in the near future. Take a sneak-peek into their requirements:

Interoperability and Patient Access (IPA)

Include interoperability features in your infrastructure for authorized sharing of members’ claim information

  • Patient Access API - Share member’s claims data on request
  • Provider Directory API - Disclose provider information on request
  • Payer-to-Payer Data Exchange - Make member data accessible between payers
Transparency in Coverage (TinC)

Provide access to cost-sharing details of items and services to customers

  • Disclosure to Enrollees
    • Seven Content Elements - Estimated cost-sharing liability, accumulated amounts, negotiated rates, out-of-network allowed amounts, a list of items and services subject to bundled payments arrangements, a notice of prerequisites, and disclosure notice.
    • Self-Service Tool - Share an estimate of cost-sharing with consumers on internet websites
    • Paper Form – Members can request an estimate of cost-sharing in paper form
  • Disclosure to Public
    • In-network Negotiated File - Disclose in-network negotiated rate based on contracts
    • Allowed Amount - Disclose allowed amount and historical bill charges
    • Drug Prescription File - Disclose negotiated rate and historical net price
Reducing Provider and Patient Burden (RPPB)

Ease prior authorization process to benefit members and providers

  • Provider Access API
  • Bulk Access APIs
  • Documentation Requirement Lookup Service (DRLS) API
  • Prior Authorization Support (PAS) API
Trusted Exchange Framework and Common Agreement (TEFCA)

Establish qualified health information networks (QHIN) and FHIR into the US healthcare ecosystem

  • Common Agreement
  • QHIN Technical Framework
  • FHIR Roadmap

Compliance Requirements

Align your business with regulatory requirements, keep your organization compliant and avoid penalties, to ensure a good standing in the market.

  • 21st Century Cures Act
  • Patient Protection and Affordable Care Act
  • American Recovery and Reinvestment Act
    • Health Information Technology for Economic and Clinical Health Act (HITECH)
  • Health Insurance Portability and Accountability Act (HIPAA)
  • Paperwork Reduction Act
  • Emergency Medical Treatment and Labor Act (EMTALA)
  • Freedom of Information Act (FOIA)
  • Public Health Service Act
  • False Claims Act
  • No Surprise Act
  • Interoperability and Patient Access
  • Transparency in Coverage
  • Reducing Provider and Patient Burden
  • Trusted Exchange Framework and Common Agreement (TEFCA)
Technology & Standards
  • X12 EDI
  • OAuth2 & Consent2Share
  • Health and Human Services (HHS)
  • Centers for Medicare and Medicaid Services (CMS)
  • Office of Inspector General (OIG)
  • Office of Civil Rights (OCR)
  • Office of National Coordinator (ONC)

How Nalashaa Can Help You?


Process blueprinting and compliance gap identification

Roadmap Planning

Chart out an execution plan with milestones


Leverage technology to realize the roadmap

Go-Live and Support

Performance consistency and continuous improvement

Align your business with regulations!

As we understand you better, we help you comprehend ways to comply with regulations.

Take the first step, and connect with our experts.

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