Solving the Payer-to-Payer Interoperability Challenge: Rhino's Harmonization Copilot Tackles CMS Mandates

The Challenge of the CMS Interoperability Mandate

This blog post will help Health IT and Digital Transformation leaders in the health insurance industry understand how Rhino Federated Computing’s Harmonization Copilot can help them comply with impending interoperability requirements issued by CMS.

The Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F) has established new requirements for insurers including Medicare Advantage organizations, Medicaid managed care plans, Children’s Health Insurance Program (CHIP) entities and Qualified Health Plans (QHPs) on Federally-Facilitated Exchanges. By January 1, 2027, these organizations must implement and maintain a Payer-to-Payer API using the HL7 FHIR standard to exchange critical patient data when individuals change health plans or have concurrent coverage.

This mandate will improve the lives of patients and providers while catalyzing innovation in health plans by producing the following benefits:

• Enhanced care continuity when patients switch between health plans
• Reduced administrative burden through automated data exchange
• Improved member satisfaction with seamless information transfer
• Support for value-based care models through comprehensive data access

Despite these benefits, the Payer-to-Payer API requirement presents significant challenges:

• Creating HL7 FHIR resources from existing claims and EHR data
• Mapping claims data to standard vocabularies like SNOMED and LOINC
• ETL version control as FHIR standards and controlled vocabularies change
• Resource constraints for design and implementation of FHIR data pipelines 

A Streamlined Solution: Rhino's Harmonization Copilot

Rhino Federated Computing's Harmonization Copilot provides an end-to-end solution for Payer-to-Payer API compliance. Payers can use the Harmonization Copilot to efficiently map their internal data as well as medical and pharmacy claims to the FHIR resources required by the CMS regulation. Unlike other software tools on the market, non-technical users are able to create FHIR data without writing code.

How Does Rhino's Harmonization Copilot Work?

The platform makes it possible for non-technical users to create extract-transform and load (ETL) pipelines to FHIR through the following product offerings:

Simplified Mapping to FHIR: Our system connects directly to your existing databases and provides an easy-to-use visual tool that helps translate your data into healthcare's standardized format (FHIR). No coding required—just point and click to map your information to the right categories like allergies, care plans, and medications.

AI-Powered Code Mapping: Our AI technology automatically translates your organization's unique medical codes into standardized healthcare language. The system prioritizes your most frequently used codes first and comes loaded with standard medical vocabularies. This dramatically reduces the time your clinical specialists need to spend on manual translation work.

Collaborative Workflow Support: We've created simple interfaces so your clinical experts can verify the AI's recommendations. Team members can work together to review and approve translations, and the system exports everything you need for your implementation team.

Compliance Acceleration: Generate standardized healthcare data in days instead of months by using our pre-loaded templates. Upload harmonized data directly to your FHIR servers and generate analytics reports to demonstrate compliance with regulations. This approach significantly reduces implementation time compared to traditional manual methods.

Implementation Approach

Payers implementing the Payer-to-Payer API with Rhino's Harmonization Copilot follow this streamlined process:

1. Automated Data Profiling: The Rhino FCP analyzes existing data structures and values in the payer's systems
2. Syntactic Mapping to FHIR resources: A data specialist uses the no-code interface of the Harmonization Copilot to map the profiled local data to FHIR resources
3. AI-Assisted Code Mapping to FHIR ValueSets: A purpose-built LLM generates recommended code mappings to standardized vocabularies like LOINC and SNOMED
4. Expert validation: Clinical specialists are sent a URL to easily review and refine the suggested mappings. No more emailing spreadsheets!
5. Production integration: Validated mappings are exported for implementation in production environments. Automations can be configured using the Rhino Python SDK. 

Beyond Compliance: Strategic Advantages

While meeting CMS requirements is essential, Rhino's solution delivers additional strategic benefits:

• Operational efficiency from automated mapping processes
• Higher data quality with expert-validated semantic mappings
• Future-proof architecture that can adapt to evolving standards
• Extensible mappings to convert FHIR pipelines into other formats, including OMOP, SDTM, and i2b2. 

Conclusion

The CMS Payer-to-Payer API mandate represents both a challenge and an opportunity for healthcare payers. By addressing the fundamental data harmonization requirements, Rhino's Harmonization Copilot transforms compliance from a burden into a strategic advantage.

As the January 2027 deadline approaches, forward-thinking payers are implementing solutions that not only satisfy regulatory requirements but also position them for success in an increasingly interoperable healthcare ecosystem. Rhino's Harmonization Copilot provides the bridge between current systems and CMS's vision for seamless data exchange, enabling better care coordination, improved member experiences, and more efficient healthcare operations.

Reach out to the team at Rhino to schedule a demo today.

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