1up Payer-to-Payer Data Exchange

Unlock historical member data with FHIR®-powered data exchange.

Member History Without the Guesswork

Too often, new members arrive with little historical context. With 1up Payer-to-Payer Data Exchange, you don’t have to start blind. Member data is automatically retrieved from previous or concurrent payers, validated, and unified – so onboarding starts with real insights, not assumptions.

Built for scale, flexibility, and CMS-0057-F compliance, 1up supports the full payer-to-payer data exchange workflow. Everything is handled in one place – from member consent and managed payer connectivity to unified member profiles, real-time activation, and usage reporting. As a result, your teams can act sooner and with more confidence.

Immediate Member Insight

Gives your care teams immediate visibility into member history, utilization, and potential care gaps from day one.

Quick, Confident Onboarding

Enables smoother enrollment and quicker program placement by reducing delays caused by missing information and manual follow-ups.

Targeted Member Experiences

Powers more personalized member outreach and timely, relevant interactions by activating member data across member services and engagement workflows.

Stronger Risk and Quality Performance

Improves risk accuracy, quality performance, and decision-making with access to more complete member information.

I like that 1upHealth is proactive in terms of staying ahead of the CMS interoperability rules. They are far ahead of what is supposed to be coming. For example, 1upHealth is already implementing rules that we are a couple of years out from. Bringing us to a compliance level ahead of the deadlines is unheard of in our business.

VP, January 2025, collected by KLAS Research

CMS Compliance Made Easy

Provides everything you need to meet CMS-0057-F payer-to-payer data exchange requirements.

Payer-to-Payer Data Exchange FHIR APIs

FHIR-based APIs with secure OAuth2 authorization for bi-directional data exchange between payers, supporting the five-year lookback period requirement.

Consent Management

Flexible opt-in workflows, including 1up-hosted and payer-hosted experiences, to capture, track, and audit member consent across lines of business.

Member Matching

Deterministic, FHIR-based member matching that accurately identifies members across payers to ensure clean, reliable data exchange.

Data Access Controls

Customizable, policy-based controls to exclude cost, remittance, sensitive, and/or non-required data from payer-to-payer sharing.

Value Driven Beyond Compliance

1up Payer-to-Payer Data Exchange goes beyond meeting requirements to enable faster onboarding, stronger data continuity, and more data-driven risk decisions.

• Lower integration costs
• Payer-to-Payer Network: Simplifies connectivity to prior and concurrent payers with an expansive one-to-many payer network.
• Reduced operational burden
• Payer Registration & Onboarding: Enables requesting payers to onboard and obtain OAuth2 credentials via a secure, self-service portal and 1up vetting process.
• Better insights
• Longitudinal Member Profile: Unifies prior-payer data with existing member information, creating a single, unified profile with source metadata.
• Better member experiences
• Real-Time Event Streams: Integrates with care management, risk, quality, and member services systems to deliver acquired data directly into existing workflows.
• Operational transparency
• Payer-to-Payer Usage Reporting: Provides visibility into inbound and outbound data exchange activity through pre-built dashboards and exportable reports.
• Lower implementation risk
• Modular Deployment: Enables modular adoption of 1up’s network and consent services while continuing to store and manage data on existing systems.

How It Works

A single, automated workflow for securely receiving and sharing member data between prior and concurrent payers.

Consent & Payer Identification

Members provide consent and identify prior or concurrent health plans during enrollment or outreach.

Secure Data Request

1up sends or receives compliant payer-to-payer data requests on your behalf using standard FHIR APIs.

Data Exchange

Verified payers securely share approved member data through the 1up Payer-to-Payer network, excluding cost and remittance information.

Validate & Unify

Incoming data is validated, tagged with its source, and unified into a longitudinal member profile.

Data Activation & Oversight

Unified data is immediately available across downstream systems, with complete visibility into activity through the 1up Console.

See 1up Payer-to-Payer Data Exchange in Action

Explore interactive product tours covering member consent and data authorization, and see how 1up unifies claims and clinical history across multiple payers for a more complete member picture from day one.

FAQs

How does 1up support member consent?
1up supports flexible opt-in workflows, including payer-hosted or a configurable 1up-hosted consent experience. Consent status is tracked, logged, and auditable, with full visibility in the 1up Console. Once consent is captured, 1up automatically initiates payer-to-payer requests and manages retrieval end-to-end.

What member matching logic is used?
1up uses deterministic matching based on member identifiers and the FHIR $member-match operation to accurately identify members across plans. The 1up Platform validates matches before retrieval and is designed to support enhanced identity management capabilities as matching needs evolve.

Which payers can members select during opt-in?
Members can choose from over 500 U.S. health plan brands across Medicare, Medicaid, and commercial plans, including national, regional, and Blues. If a plan isn’t listed, members can enter it manually, and 1upHealth will update the directory as needed.

Can we use 1up Payer-to-Payer Data Exchange with our existing FHIR server?
Yes. 1up Payer-to-Payer Data Exchange is modular, so you can use network connectivity, consent management, or data retrieval while continuing to store and manage data in your own systems, on-premise, or in the cloud.

How is payer-to-payer data delivered downstream?
Retrieved data is validated, normalized, and unified into a single longitudinal member record. Plans can access the data through FHIR APIs, bulk exports, dashboards, or downstream integrations that support care management, quality programs, analytics, and member engagement. This data is also made available via other CMS-0057-F Access APIs, including Patient Access APIs and Provider Access APIs.

Do members need to act after opt-in?
No. After providing consent, members take no further action. 1up manages data requests, retries, validation, provenance tracking, and downstream availability automatically, with operational visibility provided through the 1up Console.