Case Study: Multi-State Health Plan Data Conversion & Payer-to-Payer Exchange

Client: A consortium of U.S. Health Plans operating across Virginia, North Carolina, and Georgia.

Project Scope:To enable seamless payer-to-payer data exchange and support regulatory requirements for Prior Authorization transparency and Member Match, the client engaged HiPaaS to perform FHIR-based data conversion across multiple resource types. The goal was to modernize patient data interoperability, leveraging existing resources while creating new FHIR profiles for full ecosystem compliance.

Key Objectives

• Comply with CMS Payer-to-Payer data exchange mandates (per the Interoperability and Patient Access Final Rule).

• Improve Prior Authorization workflows via structured, FHIR-native resources.

• Enable accurate Member Match between current and previous payers.

• Ensure reusability of legacy data using FHIR mappings.

Solution Highlights

Data Sources

• Existing medical and claims data from internal systems.

• Coverage and benefit data from legacy systems across three states.

FHIR Resources Used

• Patient

• Coverage

• ExplanationOfBenefit

• Organization

• Practitioner

• AllergyIntolerance

• Condition

• DiagnosticReport

• Goal

• Observation

New Resources Created:

• Consent – Implemented using HRex Consent Profile for payer-to-payer data sharing.

• PriorAuthorization – Derived from structured conversion of ExplanationOfBenefit.

• MemberMatch – Enabled cross-payer identity verification and alignment.

Approach

1. FHIR Mapping & Profiling:

   • Mapped over 1.2M records into HL7 FHIR R4 format using the HiPaaS FHIRFlo platform.

   • Applied Da Vinci and CARIN profiles for standardization and compliance.

2. Consent Enablement:

   • Implemented a modular Consent resource framework allowing patients to control data sharing preferences between previous and current payers.

3. Prior Auth Reconstruction:

   • Extracted relevant fields from EOBs (e.g., procedure codes, status, submitter) to reconstruct actionable Prior Authorization requests in FHIR.

4. Member Matching Logic:

   • Created custom Member Match rules to align members across disparate plan identifiers, using patient demographics and coverage details.

5. Data Quality & Validation:

   • Performed normalization, enrichment, and duplicate resolution to ensure high data quality before FHIR conversion.

Outcomes

Metric	Result
Conversion Accuracy	98.7% match with original source records
FHIR Resource Coverage	100% of target profiles supported
Onboarding Time for New Payers	Reduced by 40%
Prior Auth Processing Time	Reduced by ~35% through structured exchange
CMS Compliance Readiness	Achieved ahead of deadline

Conclusion

HiPaaS delivered a scalable, standards-aligned medical data conversion and exchange platform that empowers the client to comply with evolving federal mandates while improving operational efficiency. The reuse of existing resources significantly accelerated the project timeline, and the creation of new resources ensured interoperability readiness across all participating health plans.

For more information visit us at https://www.fhirflo.com/ or email info@hipaas.com.