In a time of unprecedented transformation in the healthcare industry, staying informed and inspired is not just a benefit — it’s a necessity. That’s why Elligint Health is proud to bring you Sparking Change, our monthly e-newsletter designed especially for our clients and partners. More than just an update, Sparking Change is your strategic companion — offering insights into innovation, performance, and the people driving progress across healthcare.

Are You Ready for CMS-0057-F? Reach Out to See How Helios® Can Help

Worried about maintaining compliance with CMS-0057-F? Helios UM has you covered.

CMS’s Interoperability and Prior Authorization Final Rule (CMS-0057-F) for Medicaid and Medicare, published in January 2024, is designed to improve member and provider utilization management (UM) experiences by facilitating accountability, increasing efficiency, and digitizing how prior authorizations (PAs) are handled by payers. Among the new PA and interoperability mandates addressed by 0057F, the following requirements are key:

• PA API & Decision Timelines: Payers must implement a FHIR-based Prior Authorization Support (PAS) API to facilitate electronic PA requests. The rule mandates 7 calendar days for processing standard requests and 72 hours for processing expedited requests.
• Interoperability & Data Sharing: The rule requires Payer-to-Payer, Provider Access, and Patient Access APIs to improve seamless data exchange and reduce care delays.
• Denial Transparency: Payers must provide specific reasons for PA denials to enhance transparency.
• Public Reporting: Payers must publicly report PA metrics, including approval/denial rates and decision times, starting March 31, 2026, so that providers and the public can see how efficiently payers are handling PAs.
• Implementation Timeline: Most provisions take effect January 1, 2026, but payers have until January 1, 2027, to implement the required APIs.

Elligint Health’s Helios UM solution, which supports artificial intelligence (AI) via our unified ecosystem of partner apps to expedite PA processing, is CMS-0057-F ready. We deliver a solution that provides payers with powerful automation, FHIR APIs, seamless data sharing, PA tracking tools, and an intuitive user experience, all from within a single interface that drives efficiencies, enhances accuracy, and accelerates UM processing to help organizations meet CMS-0047-F requirements. To streamline the UM process even more, we’ll be introducing four powerful tools, slated for deployment this fall, that work in concert to revolutionize the user experience:

• Quick Navigation – streamlines movement through complex forms with dedicated navigation tools.
• Attention Guidance – provides visual cues to highlight what matters most.
• Quick Entries – enable efficient bulk actions.
• Quick References – deliver contextual information through innovative side panels.

Together, these enhancements create an even easier-to-use platform that adapts to each organization’s unique workflows while allowing healthcare professionals to focus more on patient care and less on system interaction.

Learn more about CMS-0057-F compliance and preview our new UM tools.
→ Reach out to the experts at Elligint Health today!

Building Next-Generation Analytics with AWS

Elligint Health’s Chief Technology Officer (CTO), Bradley Dick, is on a mission: To make healthcare data truly actionable. “Deriving a worklist to get to a workflow is 99% of what healthcare is,” notes Bradley. “So how do you sift through volumes of data to determine what has to be done right now? What if we could enable people who don’t have an analytics background to simply talk to the data and generate a prioritized list of tasks for today?”

Realizing this vision requires more than just ambition, it requires a robust infrastructure, data readiness, compliance with regulatory standards such as HIPAA and HITRUST, and a strong innovation partner. Bradley thinks Elligint Health is ready for the challenge and is collaborating with Amazon Web Services (AWS) — a highly trusted industry leader in scalable cloud architecture, advanced health data analysis, and AI model development tailored to the healthcare industry — to bring this vision to life within the Helios platform.

With deep experience supporting outcomes modeling across millions of patient lives, including partnerships with Rush University Medical Center, Konica Minolta Precision Medicine, and the Children’s Hospital of Philadelphia, AWS is already playing a critical role in advancing the next generation of Elligint Health’s Helios platform. Bradley and AWS are guiding Elligint Health’s analytics vision along three forward-looking paths, all aimed at helping providers act faster, with greater precision and insight:

• Real-time, Actionable Dashboards: Bradley believes that real-time dashboards that highlight sentinel metrics, such as drops in visits, increases in unaddressed care gaps, rising ER use, and other early-warning trends, will enable providers to be more proactive, productive, and efficient. “If we can surface early-warning signs in real time, providers can act before those problems escalate,” he explains.

Dashboards will be customizable and benchmarked across various levels — for example, by individual provider, practices, at the organization level, and even nationally — using de-identified data from organizations that opt in.

• Narrative Language Query (NLQ) for Data Interrogation: Elligint Health is also exploring the use of NLQ to interface with data. NQL enables users to interact with data using intuitive questions rather than code — similar to using a normative style to input questions into artificial intelligence (AI) tools such as ChatGPT — for easier data interrogation.

“For example, a provider could use an NLQ interface to type in ‘Show me all patients with these five comorbidities that have been to the ER in the last 5 days, are prediabetic, and have a postprandial blood glucose (PPG) of over 30’ to return a list of patients with the desired characteristics,” Bradley explains. “Using NLQ simplifies the process and allows care teams and payer staff as plan administrators or case managers, to obtain targeted information without spreadsheet wrangling or having to use programming syntax to compose complex data queries.”

• Predicting Susceptibility Before Illness Strikes: In its most forward-looking initiative, Elligint Health is exploring how to harness AI to detect early signals that portend declining health by using subtle patterns in data that could indicate a person is on the path to illness. By analyzing a blend of clinical history, lifestyle factors, genetic markers, and environmental data, the aim is to proactively identify at-risk individuals and initiate timely interventions well before symptoms emerge and costs to escalate.

“Medicine today doesn’t practice health care — it practices sick care,” says Bradley. “But how can we combine data on comorbidities, lifestyle, and genetics to identify susceptible people before they get sick and then arrange interventions? If we get this right, it could fundamentally change the practice of medicine, improve health outcomes, and significantly reduce costs for both payers and members.”

“These are the next-generation technologies we’re building into our platform to transform healthcare,” says Bradley. “Take diabetes, for example — once someone is diabetic, the diagnosis often lasts a lifetime. But if we can identify risks early and intervene before the disease starts — that’s game-changing. And that’s the future we’re trying to build.”

 

Elligint Health Welcomes Deon Health

Elligint Health is thrilled to partner with our newest client — Deon Health — in their mission “to give individuals with disabilities the power to live their best life by transforming community and healthcare support systems.” Deon Health does this by supporting providers, families, and the communities and payers dedicated to serving individuals with intellectual and developmental disabilities (I/DD). Historically, care coordination for individuals with I/DD has been insufficient, and we are proud that Deon Health has chosen our Helios® platform to help drive meaningful improvements.

“We chose Elligint Health because of their ability to integrate significant amounts of data from the community and healthcare support systems in a simple way to drive action and outcomes. From our first meeting, we knew the Elligint Health team shared our commitment to improving the healthcare experience for the I/DD community.”

Shane Spotts
Founder and CEO of Deon Health

Based in Fort Gratiot, Michigan, Deon Health specializes in coordinating and delivering person-centered care for individuals with I/DD who are eligible for Medicaid and Medicare, with a strong focus on home and community-based services. Founded on a deep commitment to providing appropriate, compassionate, and high-quality care for individuals with I/DD, Deon Health is dedicated to making a difference in the lives of their members.

Welcome, Deon Health — we’re excited to embark on this impactful journey together!

For more information about Elligint Health or Helios, contact your Account Manager today.