NEHEN 3.0 is the project name for the next version of NEHEN, a cost-effective, collaborative, open standards-based exchange of clinical and administrative data, implementing priority use cases to move the community forward toward automation for prior authorization and quality measurements. It will meet customers where they are currently and provide a pathway to the future by supporting both X12 and FHIR-based clinical and administrative exchange.
What is NEHEN 3.0
- NEHEN 3.0 will focus on reducing burden and minimizing operational and capital expenditures for participating organizations, while advancing the exchange of clinical and administrative data between payers and providers
- Through a common platform, NEHEN 3.0 will support both the X12 based (HIPAA mandated) EDI transactions, as well as new API / FHIR based clinical use cases
- Initial services will include current EDI transactions such as eligibility verification and remittance advice (ERA), as well as FHIR transactions supporting initial use cases of prior authorization and quality measures
- Community-wide governance will determine future features and use cases that offer the most value to NEHEN 3.0 trading partners
Features
- Cost-effective, collaborative, open standards-based exchange of clinical and administrative data
- Inclusion of FHIR API exchange services, centrally hosted plus optimized X12 EDI services via a service-model delivery in support of payer-provider collaborative use-cases
- Initial focus on priority use cases for prior authorization and quality measures data exchange
- Iterative delivery and advancement of API based use-cases governed in a collaborative, member driven approach
- Meeting customers where they currently are technically, while providing a pathway to the future
- Shared services delivery model with community governance in a collaborative, evolving, and adaptive planning process
- Continual innovation, advancement, and adoption
- Culture of serving end-user needs and operational workflows
- Transparency among community and broader industry
- À la carte service options depending on needs, including choice of passthrough transactions or hosted services when both are offered
- Standards based exchanges with adaptations to meet members where they are today with a path to the future
Initial FHIR API Transactions
Coverage Requirements Discovery (CRD)
- Passthrough FHIR to payer’s hosted CRD rules engine
- Shared CRD service, hosted by NEHEN on behalf of our health plans (optional)
Documentation Templates and Rules (DTR)
- Passthrough FHIR to payer’s hosted DTR service
- Shared DTR service, hosted by NEHEN on behalf of our health plans (future)
Prior Authorization Support (PAS)
- Passthrough FHIR to payer’s prior authorization system for automated approval
FHIR-Based Quality Measures
- FHIR-based bulk clinical data exchange (exchange all quality measures data at once).
- Measure specific FHIR transactions (ex: QM & DEQM IGs)
Other CMS APIs
- Patient Access API
- Provider Directory API
- Provider Access API
- Payer-to-Payer API