Interoperability and IT
Teams responsible for the federal API requirements and data exchange.
- Patient Access, Provider Access and Payer-to-Payer APIs
- Mapping claims and clinical data to FHIR
- API security and member authorization
Healthcare / Payers and Health Plans
Software development for health plans and payers
Health plans face federal API rules, slow prior authorization and member experiences that lag behind retail. Agnotic Technologies builds payer software for interoperability APIs, prior authorization, member and provider portals and claims automation, working in FHIR and X12.
CMS-0057-F
Interoperability and prior authorization APIs
FHIR R4 · X12
The standards payer data moves in
Da Vinci
HL7 implementation guides for payer workflows
Trusted by global innovators
Industry Overview
What is payer software development?
Payer software development is building the systems health plans use to exchange data, decide prior authorizations, pay claims and serve members and providers. Agnotic Technologies builds these for health plans and insurtech companies, including the FHIR APIs required by CMS-0057-F, connected to the core administration system you already run.
Who it is for
Which payer teams do we work with?
Payer programs cross several departments. These are the teams that usually own the work.
Utilization management
Clinical teams that review prior authorization requests.
- Requests that arrive by fax and phone
- Missing documentation that delays decisions
- Decision timeframes to meet and report
Member experience
Teams that own apps, portals and the call center experience.
- Members who cannot find benefits or claim status
- Calls about questions an app could answer
- Accessibility for every member
Claims and provider operations
Teams that pay claims and support the provider network.
- Claims pended for missing information
- Provider calls about eligibility and claim status
- Directory data that goes out of date
Industry Challenges
Where do payer operations lose time?
The same manual work shows up across most health plans, and each step is a candidate for automation.
Prior authorization by fax and phone: requests arrive incomplete and staff chase documents by hand.
Data requests answered manually: member and provider requests for records go through email and file transfers.
Portals that send members to the phone: when the app cannot answer a question, the call center does.
Claims pended for information: claims wait for data that could have been checked when they arrived.
CMS-0057-F API checklist
Which APIs does CMS-0057-F require?
The four FHIR APIs in the CMS Interoperability and Prior Authorization Final Rule, and the HL7 implementation guides commonly used to build them.
| API | Who uses it | What it shares | Common implementation guides |
|---|---|---|---|
| Patient Access API | Members, through apps they choose | Claims and encounter data, clinical data and prior authorization information | CARIN Blue Button, US Core, Da Vinci PDex |
| Provider Access API | In-network providers with a treatment relationship | Claims, clinical and prior authorization data for their patients | Da Vinci PDex, US Core, Bulk FHIR |
| Payer-to-Payer API | The member's new health plan, with the member's permission | Claims, clinical and prior authorization data when a member changes plans | Da Vinci PDex |
| Prior Authorization API | Providers and their EHRs | Whether authorization is required, what documentation is needed, and the request and decision | Da Vinci CRD, DTR and PAS |
Our Approach
How can claims and prior authorization be automated?
Automation handles the routine cases so clinical reviewers and claims staff spend their time on the exceptions.
Requirements at the point of order
Providers see whether authorization is needed while ordering, through Da Vinci CRD.
Documentation from the EHR
Required documentation is gathered from the provider's EHR through Da Vinci DTR, not by fax.
Rules for clear cases
Requests that meet your criteria are approved automatically; everything else goes to a clinical reviewer.
Claims checked on arrival
Missing or inconsistent claim data is caught at intake, before the claim pends.
Capabilities
What do member and provider portals need?
Self-service that answers the questions members and providers would otherwise call about.
Member app
Digital ID card, benefits, claim status and finding in-network care.
Provider portal
Eligibility checks, prior authorization submission and claim status for network providers.
Provider directory
Directory data published through FHIR and kept current from your source systems.
Secure messaging
Messages between members, providers and plan staff, with an audit trail.
Accessible design
Interfaces designed and tested against WCAG accessibility guidelines.
Consent and app authorization
Members approve third-party app access through OAuth, and can revoke it.
Engineering Stack
Which standards and technologies do payer projects use?
The transactions, implementation guides and platforms we work with on payer engagements.
FHIR guides
US CoreCARIN Blue ButtonDa Vinci PDexDa Vinci CRDDa Vinci DTRDa Vinci PAS
X12
837835270/271276/277278
Security
OAuth 2.0OpenID ConnectSMART on FHIR
Backend
JavaNode.jsPythonPostgreSQL
Infra
AWSAzure
Measured Impact
Which measures matter for payer API and prior authorization programs?
Measures we build reporting around. CMS-0057-F also requires impacted payers to publicly report certain prior authorization metrics.
Decision time
Prior authorization turnaround
Time from a complete request to a decision, for standard and expedited requests.
Electronic share
Requests received through the API
Prior authorization requests that arrive electronically instead of by fax or phone.
Uptime
API availability
Share of time the FHIR APIs respond correctly.
Adoption
Digital member use
Members who use the app or portal for a task they used to call about.
My Lauren Maternal Health Platform | Built by Agnotic
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Case Study
LERA Health: Compliant Women’s Health App Platform
A women’s health product experience focused on guided care journeys, education, and compliance-aware workflows to support long-term engagement.
Case Study
Use Cases
Which payer organizations do we build for?
Payer types with different rules, members and systems.
01
Medicare Advantage plans
API programs, prior authorization and member engagement for Medicare members.
02
Medicaid managed care
Interoperability and member access across state program requirements.
03
Marketplace health plans
Member apps and data exchange for qualified health plan issuers.
04
TPAs and self-funded plans
Claims and member tools for administrators serving employers.
05
Insurtech startups
New plan models and member experiences built on modern APIs.
06
Value-based care programs
Data sharing and reporting between plans and provider partners.
Integrations
Which systems do we integrate for health plans?
Connections between payer systems and the people and organizations that need their data.
Core
Your core administration system
Interoperability
FHIR server
EDI
Clearinghouses (X12)
Providers
Provider EHRs
Security
Identity provider
Analytics
Data warehouse
Compliance-First Development Services Backed by Global Standards
We build secure, scalable products designed for privacy, interoperability, and regulatory readiness from day one across every sector we serve.
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, and strict access controls.
Fast Healthcare Interoperability Resources
Enabling standardized health data exchange through standards-based API mappings.
Our Edge
Why Global Leaders Choose Us
We combine deep technical expertise with industry-specific knowledge to deliver solutions that aren't just functional, but transformational.
Enterprise-Grade Security
We implement rigorous security protocols and compliance standards (HIPAA, GDPR, SOC2) across all industrial solutions to protect sensitive data.
High-Performance Scaling
Our architectures are built to handle massive data loads and user bases, keeping performance steady whether you're serving ten or ten million.
Accelerated Time-to-Market
Using our suite of internal tools and proven frameworks, we reduce development cycles and get your product to market 40% faster.
Embedded AI Integration
Beyond simple wrappers, we build deep-learning integrations and predictive analytics directly into the core of your industry-specific workflows.
Engagement Model
How does an engagement with a health plan work?
We sequence work around your regulatory deadlines and your core system's release cycle, and agree timing on the scoping call.
01
Scoping call
We agree which APIs, workflows or member tools come first.
02
Data mapping
We map your core system's data to the FHIR implementation guides.
03
Build and test
We build the APIs or applications and test them against the implementation guides and with real partners.
04
Launch
Production release with monitoring, logging and runbooks.
05
Scale and support
More APIs, partners and workflows under agreed support terms.
Facts and sources
Which rules shape payer software?
Short facts on the regulations behind payer software, each linked to its official source.
The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) requires impacted payers to implement FHIR APIs, including a Prior Authorization API, and to publicly report certain prior authorization metrics.
Source: Federal Register, February 8, 2024 (CMS-0057-F)The earlier CMS Interoperability and Patient Access Final Rule (CMS-9115-F) first required impacted payers to offer a Patient Access API based on HL7 FHIR.
Source: Federal Register, May 1, 2020 (CMS-9115-F)HIPAA names the ASC X12 278 as the standard transaction for health care services review requests and responses, which includes prior authorization.
Source: 45 CFR Part 162 Subpart M (eCFR)The HIPAA Security Rule requires administrative, physical and technical safeguards for electronic protected health information.
Source: 45 CFR Part 164 Subpart C (eCFR)
Voice of success
We don't just build products; we forge lasting partnerships. See how we've helped industry leaders transform their vision into technical reality.
“I can clearly see how Agnotic has a unique way of handling end-to-end development. They are always active on quick chat and provide support quickly.”
Aaron Phelan
Founder, Benchmark
“Agnotic combines deep technical expertise with strong domain knowledge. They understand the business context, anticipate challenges, and make collaboration smooth and effective.”
John Pasmore
Founder, Latimer
“Agnotic is the best technical team we evaluated. Their engineering excellence made our work dramatically easier and allowed us to stay focused on what matters most for maternal care outcomes. They took full ownership of the technical execution, and we are always happy to continue working together.”
Kim Smith
Founder, My Lauren
Related services
Where can health plans start with us?
Detailed pages for the services payers and insurtech companies ask us about.
Prior authorization automation
AI agents that gather documentation and route requests for review.
Claims processing automation
Claim intake, checks and status tracking.
Claims adjudication software
Edits, pricing rules, pend queues and 835 remittance for payers and TPAs.
Payer core administration
Enrollment, benefits, provider data and claims platforms, built or modernized.
Payer operations software
Service, appeals and authorization workflow tools.
Value-based care platforms
Data sharing and analytics for value-based contracts.
FHIR development services
FHIR APIs and SMART on FHIR apps.
Remote patient monitoring software development
Device data, care team workflows and billing support for RPM programs.
Telemedicine platform development
Virtual visit platforms with scheduling, video and EHR integration.
EHR software development
Custom EHR modules and platforms built around clinical workflows.
HIPAA requirements for software teams
The safeguards we build into every healthcare product.
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Cross-Industry Reach
The Same Engineering Patterns, Across Other Industries
The technical patterns behind this platform translate naturally into adjacent verticals.
Frequently Asked Questions
Four FHIR APIs: an expanded Patient Access API, a Provider Access API, a Payer-to-Payer API and a Prior Authorization API. Implementations commonly follow HL7 guides such as CARIN Blue Button, Da Vinci PDex and the Da Vinci prior authorization guides (CRD, DTR and PAS). The rule also sets prior authorization decision timeframes and public reporting of prior authorization metrics.
It applies to Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities and issuers of qualified health plans on the Federally-facilitated Exchanges.
Yes. We connect to the core administration system you run through its APIs, database extracts or file feeds, and map its enrollment, claims and authorization data to FHIR. The core system stays the source of truth; the API layer reads from it rather than replacing it.
We build automation that checks requirements, gathers documentation and approves clear cases under your rules. Requests that need clinical judgment go to qualified reviewers, and we design the workflow so every decision can be traced and explained.
Industries
A Unified Vision that Caters to Diverse Industry Demands
Build payer APIs and workflows that members and providers can use
Tell us which APIs or workflows come first, and we will scope a first release with you.
contact@agnotic.com
Partnerships
contact@agnotic.com