Wednesday, September 7, 2022

Cures Act Compliance with CognitiveScale Accelerates Hyper-Personalized Member & Patient Insights

The 21st Century Cures Act (“Cures”) requires that federally regulated payers must be able to exchange patient health information directly with other payers, providers, and the patients themselves.

Meeting the requirements of the Cures Act presents payers with challenges and opportunities that CognitiveScale is uniquely capable of addressing with our technology.

The 21st Century Cures Act (December 2016) includes provisions for expanding health sciences research; improving access to addiction and mental health services; and advancing Healthcare Information Technology (HIT). But it is the mandates that patients have access to an increased amount of their own medical information in Patient Data Access provisions that makes the Cures Act such a challenge. Additionally, Cures targets the practice of information blocking by requiring electronic health record (EHR) systems to be more interoperable.

The goals of the CMS Interoperability and Patient Access rule, a subset of the Cures Act, are twofold: 1) to advance information exchange between payers, patients, and providers; and, 2)  to ensure that individuals served by CMS regulated payers have secure and timely access to their health information.

The CMS Interoperability and Patient Access rule applies to information exchange between payers; payers and providers; and information exchange from both providers and payers to patients. However, the CMS rule only applies to CMS-regulated payers in programs like Medicare Advantage, ACA plans issued on the Federally Facilitated Exchanges, Medicaid managed care plans contracted to states, and more.

Cures Act Requirements for Payers

The CMS rule requires that patients or their designated representatives have access to the following health information from payers:Access to patient data via a Patient Access API: The Cures Act requires to make data available to patients, with specific timeframes for each of these, via specific file formats (e.g. FHIR):Access to patient data via a Patient Access API: The Cures Act requires to make data available to patients, with specific timeframes for each of these, via specific file formats (e.g. FHIR):

  • Access to patient data via a Patient Access API: The Cures Act requires to make data available to patients, with specific timeframes for each of these, via specific file formats (e.g. FHIR):
    • Adjudicated claims (including provider remittances and enrollee cost-sharing)
    • Encounters with capitated providers
    • Clinical data, including laboratory results if maintained by the impacted payer
    • Formulary information for Medicare Advantage prescription drug plans 
    • Information about covered outpatient drugs and preferred drug lists
    • Data with a date of service on or after January 1, 2016
  • Medication data: The CMS rule requires payers to make medication coverage information easily accessible to patients. For Part D Medicare Advantage plans, for example, this means formulary information lists must be available via the Patient Access API.
  • Data exchange between payers: CMS regulated payers must share health data with other payers at the patient’s request. Patients have up to five years after their coverage ends to submit such a request. This will allow payers receiving health information from another payer to maintain a cumulative health record – informing population health activities, reducing clinician burden, and minimizing delays associated with prior authorization activities.
  • Provider directory access: Payers must maintain a provider directory that lists the names of and demographic information for all covered providers.

Cures Act Compliance Timeline

Challenges with Cures Act Requirements & Longitudinal Patient Records

The Cures Act is creating a whole new set of challenges with patient information sharing (or interoperability) in healthcare. Longitudinal patient records as well as other Cures Act requirements go well beyond the data aggregation capabilities of traditional Master Data Management (MDM) or “Customer 360” solutions, or even Customer Data Platform (CDP) solutions that are more Marketing- and Sales-centric.

Cures Act

Challenges with longitudinal patient records per Cures Act requirements: A longitudinal patient record consisting of adjudicated claims, encounter, clinical data (e.g. lab results), medication information, formulary information, and more will require:

  • Improved Patient Identification: Payers will need a single source of truth for Member, Plan, Group, Provider, Claim, etc. data in order to make an individual patient’s data available to meet Cures Act requirements and stay in compliance with data sharing regulations. This could involve Artificial Intelligence (AI) to help improve confidence in identity resolution for example.
  • Rules Engines and Decisioning Systems: A longitudinal record requires more than aggregation of data. Data for the right member, with the right plan and group identification, tied to the correct provider list and formulary can require logic, rules engines or decisioning systems in order to collect the appropriate data, attach it to a Member/Patient profile, and then share it.
  • Reusable assets in order to scale Cures Act compliance across all health plans and patient-member populations: An ability to manage data connectors (APIs) and link to continuously changing provider lists, for example, are examples of reusable assets that will help payers scale Cures Act solutions across all lines of the business that are affected. Data connectivity and interoperability will be enhanced with better data connectors to internal data sources (claims and benefit systems) and external data recipients (via Cures Act standards like FHIR).
  • Monitoring solutions for data access
  • Version control and temporal views of patient profiles: There may be the need to go back in time to earlier versions of a patient record.

Longitudinal Patient Records with CognitiveScale


CognitiveScale’s Cortex Enterprise AI platform with built in capabilities like Profile-of-One enable payer organizations to comply with Cures Act requirements and then use Member/Patient Profiles across the enterprise to light up numerous AI-powered personalization and business goal optimized campaigns.

Profile-of-One is a:

    • Dynamic, longitudinal view of a Patient or Member profile, history and interactions at an enterprise level
    • Source of truth for a Single Identity

Cures Act

  • Aggregation of internal and external declared data, real-time observations, and inferences that provides a single connected patient or member view

Profile-of-One can support Cures Act compliance:

  • Aggregate all of the data required and provide a platform for distribution of data to outside parties
  • Scale Cures Act compliance across multiple lines of business and health plans with reusable assets like data connectors (APIs), rules engines, and skills
  • Light up numerous AI-powered Personalization use cases based on model outputs and decisioning systems as well as other insights and inferences derived from the declared and observed data in Member/Patient profiles
  • Fuel hyper-personalized real time member-patient journeys and interactions - more of a “guided path” - with personalized interventions, for example
  • Transform member-patient experiences from discrete transactional interactions to real time, wholesome and intelligent customer relationships that impact specific business goals (better outcomes, higher quality, lower costs, etc.).

Summary: Leverage Cures Act Compliance Solutions to Accelerate Personalized Member-Patient Insights

Member profiles built on claims, benefits, medication, prescription and provider data can light up numerous Care Optimization and Service Experience use cases. CognitiveScale’s Cortex Enterprise AI platform and Profile-of-One capabilities for Cures Act can then accelerate numerous AI use cases in areas like AI-powered Personalization and Business Goal Optimized AI.

Cures Act

Learn More

Contact us to explore how we can help your organization address Cures Act compliance challenges and opportunities. 

Email: sales@cognitivescale.com

Phone: 1-855-505-5001


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