A Regional Blues Health Plan Modernizes Its Interoperability Foundation

How a leading Blues plan tackled phased CMS-0057 deadlines, seven utilization management vendors, and a legacy platform on borrowed time — and came out ahead.

Who They Are

Plan Type

Regional Blues Health Plan

Lines of Business

Commercial & Medicare Advantage

Members Served

3+ Million

The Challenge

This regional Blues health plan was navigating a perfect storm. CMS-0057-F introduced phased compliance deadlines across Prior Authorization, Provider Access, Payer-to-Payer Data Exchange, and Patient Access. The BCBSA Interoperability Hub mandate — requiring all Blues plans to route Electronic Prior Authorization and Provider Access transactions between Home and Host Plans — added another layer of complexity.

To make matters worse, the incumbent FHIR repository vendor’s license was expiring and years of data quality issues had eroded confidence. Prior authorization workflows were also fragmented across seven delegated utilization management (UM) vendors.

Additionally, standing up a Payer-to-Payer Data Exchange network meant managing every connection, establishing a vetting process, and taking on ongoing relationships, an operational burden the team had neither the capacity nor the desire to take on.

The Stakes

• Multiple CMS-0057-F Compliance Deadlines
• 4 APIs Required on a Single Platform
• 7 Delegated UM Vendors Managed
• 0 Payer-to-Payer Connections or Infrastructure In Place
• BCBSA Interoperability Hub Blues-Specific Routing Requirement

What They Needed

The plan went to market with a formal RFP. They weren’t just looking for a compliance vendor, they needed a partner who could take on the complexity.

Their requirements:

• Patient Access and Provider Access APIs at scale
• Payer-to-Payer Data Exchange with a managed payer network
• Electronic Prior Authorization orchestration across all delegated vendors
• BCBSA Interoperability Hub connectivity without requiring an in-house build
• A single FHIR repository unifying data across all lines of business
• A replacement for the legacy platform with better data quality, transformation, and reconciliation capabilities, and a clear migration path

The Solution

A Single Platform with Superior Data Quality

1upHealth won the competitive RFP, displacing the incumbent vendor. Unlike the legacy platform, the 1up Platform was built to do more than just store FHIR data. It gave the plan a single architecture for the full CMS-0057-F mandate. It also solved the data quality problem the legacy system never could, ingesting data from source systems and normalizing it into a consistent, reliable model.

Intelligent Routing Across All Utilization Management Vendors

For a plan juggling prior authorization across multiple utilization management systems, 1upHealth’s Intelligent Routing Engine was a particularly strong fit. Rather than forcing providers to navigate each UM separately, it created one consistent entry point, automatically directing requests to the right system behind the scenes.

BCBSA Interoperability Hub Connectivity, Fully Managed

1upHealth also took BCBSA Interoperability Hub connectivity off the plan's plate entirely, managing the routing of transactions between Home and Host Plans without requiring the plan to build or maintain that infrastructure.

A Pre-Built Payer Network

On the Payer-to-Payer side, the decisive factor was 1upHealth's network strategy. Where other vendors offered point-to-point connections or had no answer at all, 1upHealth brought a pre-built, managed one-to-many payer network. Every connection, vetting process, and ongoing relationship is fully owned by 1upHealth, not the plan.

A Partner Who Stepped Up When It Mattered

When the incumbent vendor became uncooperative post-RFP, 1upHealth accelerated the migration — keeping data exchange operations running while absorbing the heavy technical lift internally.

1upHealth worked shoulder-to-shoulder with our team to accelerate the migration timeline. Their willingness to take on complexity made this transition possible under a very tight deadline.

The Result

Immediate Impact

• Providers connect once, regardless of which utilization management vendor handles the request
• Internal teams freed from data transformation and reconciliation
• Instant access to a growing one-to-many payer and provider network, where each new connection makes the network more valuable
• Active BCBSA Interoperability Hub participant for inter-plan Prior Authorization and Provider Access
• Migration completed ahead of schedule despite an uncooperative incumbent vendor

What’s Next

• Standardized, AI-ready data that can be queried and activated across quality measures, risk adjustment, and care management programs
• Positioned for the next wave of requirements, including DQM/HEDIS reporting via FHIR, the National Provider Directory, and CMS-0062-P
• A clear path to expanding long-term value with future 1upHealth products that bring in clinical data from EHRs and combine it with claims for the most complete picture of each member

With 1upHealth managing our Hub connectivity and Prior Authorization routing, providers connect once, and we handle the rest. That simplicity across the Blues ecosystem is what set the 1up Platform apart.