Automation, APIs and Authorizations Take Center Stage at Altruista Health

There’s a lot of buzz about innovation in healthcare and breakthroughs are extremely important in the effort to push value-based care forward. Altruista Health is adopting cutting-edge Application Program Interface (API) technologies and automation to help payers keep up with the speed of healthcare. It is an exciting time to be innovating because the need is tremendous, and the opportunities are so great.

Altruista Health’s GuidingCare® platform supports technologies such as FHIR API to accelerate technical consolidation and data integration efforts, while adopting automation in care coordination, utilization management, and appeals and grievances workflows. GuidingCare’s Integrated API suite boasts additional capabilities to ease integration with existing systems and inject automation into GuidingCare workflows.

GuidingCare’s Integration API suite provides a variety of services via Altruista’s Care Management, Utilization Management, and Appeals & Grievances modules. Care Management services include activities, assessments, care team composition, care plan and service plan. Utilization Management services include authorization submission and retrieval. The Appeals & Grievances module includes complaint look-up, complaint submission and updates, and the ability to assign activities, notes, documents and guidelines to a complaint.

The Integration API is provided for B2B communication between clients, partners and GuidingCare. Health plans can use GuidingCare’s Integration APIs to integrate with other systems in their ecosystems, including, but not limited to, their existing provider portals, member portals or business rules engines. The functions of API suites in provider portals and member portals vary based on the designed activities. Following are some of the ways Altruista is putting APIs to work for health plans:

Authorization API Suite. Health plans can integrate their provider portals with GuidingCare using APIs to the following effect:

  • Providers can submit authorizations through the plan’s provider portal, and the API can automatically add that authorization to GuidingCare UM workflows (for example, medical reviews and letter generation).
  • Authorization decisions are guided by clinical guidelines from InterQual Connect™ or MCG Cite AutoAuth.
  • A provider can also search and view authorizations in a plan’s provider portal, and GuidingCare’s Authorization APIs can automatically feed the latest authorization details (for example, authorization status or approved/declined units for requested services) to the plan’s provider portal.
  • Users can create and update authorizations with custom fields.
  • Users can manage authorization assignments and add documents, notes and guidelines to an authorization.
  • Health plans can integrate with their rules engine to automate the review and decision-making process.
  • Health plans can expose authorization details on their provider and member portals.

Service Plan API Suite. Health plans can use GuidingCare’s Service Plan API Suite with the following results:

  • A health plan provider portal can display all the service plans assigned to a provider by care staff. These service plans are created in GuidingCare and can be made available in the plan’s provider portal.
  • A provider can acknowledge the service plan in the health plan’s provider portal, or make notes and request adjustments, and these changes will automatically flow into GuidingCare.
  • A plan’s member portal can display all the service plans built for a member by care staff. These service plans are created in GuidingCare but made available in the health plan’s member portal.
  • The member can acknowledge the service plan in the plan’s member portal, or make notes and request adjustments. These changes will automatically flow into GuidingCare.

Complaint API Suite. This API suite supports creation of new complaints and retrieval and updates of existing complaints.

  • Health plans can retrieve complaint summaries and complaint details for a member/provider.
  • Health plans can automatically add, update or assign notes, documents, activities, guidelines, or additional participants to a complaint.

Activity API Suite. Users can create activities around a member and care staff as well as getting the list of activities on a member record. Health plans can enhance their care management functionality by automatically creating activities for care staff or creating alerts on a member, based on external triggers.

Assessment API SuiteUsers can retrieve assessment templates and submit assessment responses. Health plans can integrate assessments with external tools (such as a third-party or member portal) to automatically submit assessment results to GuidingCare. For example, if a member is using a health plan’s member portal to take an HRA, that portal can submit the member’s answers to GuidingCare systematically.

Member Eligibility. The Member Eligibility API provides all eligibility details for a member. It supports searching by a variety of patient identifiers, such as ClientPatientID, CarrierMemberID, MedicareID or MedicaidID. The API displays eligibility status and details, and returns basic member demographics.

Codes API Suite. Users can retrieve diagnoses codes, procedure codes, procedure modifier codes and medication codes based on the search text provided.

Member API SuiteUsers can look up a member’s care team, create alerts and add health notes and documents for a member.

APIs for SDOH. Healthify’s APIs on GuidingCare will make it easy for health plans to identify social needs among their members, identify the right social service providers to address those needs, coordinate referrals among clinical providers and community resources, and track outcomes.

Business Rules Engine. Using the Authorization API Suite, a health plan can retrieve the details on newly submitted authorizations, run them through their rules engine, and update GuidingCare with automated decisions (auth status approved, pended or denied; and the relevant units that are approved/denied).

Decision Rules API. The Decision Rules API allows the Authorization Portal to integrate with an external rules engine to aid in the decision process.

Altruista has also made strides in automating clinical workflows within the GuidingCare technology platform. Among the most innovative are the care coordination capabilities to stratify risk, integrating CDPS and HCC models, incorporating service plans and the data migration assistant (DMA).

GuidingCare also features automation that leads the way in utilization management and appeals and grievances, with automated preauthorization and messaging, batch letter configuration, and UM and AG packets in which a member’s data can be saved and retrieved as necessary. 

There’s a reason GuidingCare is the largest and most widely adopted platform of its kind in the United States. It’s all about Altruista Health innovation!

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