Health Plans — Commercial, Medicare Advantage, Medicaid
Insurance entities that provide health coverage to enrolled populations. They pool risk, collect premiums, define benefit structures, build/manage provider networks, and pay claims. Three major lines of business: Commercial (employer/individual), Medicare Advantage (CMS-contracted private Medicare), and Medicaid Managed Care (state-contracted).
25
Primary Modules
8
Key API Integrations
12
Regulatory Requirements
Primary Portal Modules
Products Enrollment Claims Providers Auth Financial Risk Pools Analytics Care Coordination Population Health Grievances Compliance Regulatory Billing Patient Communication Clinical Medications Employer Groups Alerts Documents Tenants Code Management Content Vitals
Organizational Relationships
▲ Vertical — Reports To (Upward)
- State DOI (Commercial)
- CMS (Medicare Advantage, Marketplace)
- State Medicaid Agency
- DOL (employer plans)
- NCQA/URAC (accreditation)
▼ Vertical — Oversees (Downward)
- Delegated entities (IPAs, PHOs, MSOs)
- Contracted vendors (PBMs, dental, vision)
- Provider networks
- TPAs (for ASO/self-funded)
▶ Horizontal — Collaborates With (Peer)
- Provider groups/IPAs/PHOs
- ACOs (value-based arrangements)
- FQHCs (safety-net access)
- Hospitals and health systems
- Employers and brokers
- TPAs
- PBMs
- Reinsurance carriers
- HIEs
- Actuarial consultants
Key API Integrations
CMS HPMS/MARx/Stars/Risk AdjustmentFull X12 EDI SuiteFHIR Interoperability (all CMS-mandated APIs)NCPDP PharmacyHEDIS/CAHPS QualityPrice TransparencyCAQH/NPPES Provider DataState Medicaid Interfaces
Regulatory Requirements
- State insurance licensure/RBC (Commercial)
- CMS Part C/D regulations (MA)
- 42 CFR Part 438 (Medicaid MC)
- NCQA/URAC accreditation
- ACA requirements (EHB, MLR, guaranteed issue)
- Network adequacy
- CMS Interoperability Rule
- No Surprises Act
- Mental Health Parity
- Stars quality system (MA)
- EQRO audits (Medicaid)
- Health equity requirements