Clinical systems · FHIR interoperability for health plans
1upHealth
1upHealth is FHIR interoperability software for health plans that runs the patient access, payer-to-payer, provider access, and prior authorization APIs CMS rules require.
Strong fit
- Health plans and Medicaid agencies working toward the CMS interoperability and prior authorization rule (CMS-0057-F)
- Payers that want the required patient access, provider access, and payer-to-payer data connections (FHIR APIs) from one vendor
- Plans that want a steady flow of clinical data for HEDIS and Star ratings work
Weak fit
- Provider groups that want a records network for their own clinicians
- Small practices that need fax and Direct messaging
- Buyers who want an analytics-first population health platform
Bottom line
1upHealth is a Boston company that sells FHIR data software to health plans. Plans use it to run the patient access, provider access, payer-to-payer, and electronic prior authorization APIs that federal CMS rules require, and to bring clinical data into quality programs. It fits payers whose main job is meeting those rules on time.
Score breakdown
Weights: Outcomes 35% · Product 30% · Implementation 20% · Pricing clarity 15%.
1upHealth was founded in 2017 in Boston. Andrew Boyd, a former executive at Virgin Pulse (now Personify Health), became chief executive in October 2024.
Its products line up with the data connections that federal rules require health plans to offer. They include 1up Patient Access, Provider Access, Payer-to-Payer Data Exchange, Provider Directory, Formulary, and Electronic Prior Authorization. A separate product, Clinical Connect, sends a steady flow of clinical data to plans for HEDIS and Star ratings work.
More than 80 healthcare organizations use the platform, as of October 2024. Its typical buyer is a health plan that has to deliver the CMS interoperability and prior authorization connections by a set deadline.
Compare Health Gorilla when a plan also needs QHIN access, and Kno2 when the work is connecting providers and post-acute facilities.
Competitor landscape
| Vendor | Overall | Ease of implementation |
|---|---|---|
| Particle Health | 7.4 | 7.0 |
| Kno2 | 7.3 | 7.3 |
| Zus Health | 7.2 | 7.0 |
| Metriport | 7.2 | 7.2 |
| Redox | 7.1 | 6.8 |
| Smile Digital Health | 7.1 | 6.6 |
| Onyx | 7.0 | 7.0 |
| Health Gorilla | 6.9 | 6.8 |
| 1upHealth | 6.7 | 6.5 |
Pricing
| Item | Detail |
|---|---|
| Model | A yearly subscription for health plans, usually priced by the number of members covered and the connections and modules needed. |
| What usually drives cost | How many members you cover, how many of the CMS-required connections you need, how much prior authorization work is included, and any clinical data feeds you add. |
| What to ask before you buy | The yearly price for your number of members, the setup fee for each connection, and what support costs after launch. |
| Published pricing | 1upHealth does not publish a price list. |
Prerequisites for purchase
| Need | Why it matters |
|---|---|
| What you need to get 1upHealth to function | |
| A plan for the CMS deadlines | The rule's dates decide what you must build first. |
| Claims and clinical data sources identified and mapped | The connections can only share data you have loaded. |
| Provider directory data cleaned | Errors in directory data cause the directory connection to fail. |
| Prior authorization rules digitized | Electronic prior authorization only works when your rules are written in a form software can read. |
| Compliance owner at the plan | Someone at the plan has to approve each connection. |
| What will maximize your value | |
| Load clinical data alongside claims | Quality teams get more value from the same work. |
| Test payer-to-payer exchange with real partners | A connection can meet the rule and still fail to exchange data with other plans. |
| Track API usage after go-live | It shows whether members and providers use it. |
| Deal-breakers | |
| You are a provider, not a health plan | |
| No one at the plan owns the data | |
| You mainly want an analytics platform | |
Value creation time frame
| # | Stage | Typical range |
|---|---|---|
| 1 | Data mapping and loading | 6-10 weeks |
| 2 | API build and testing | 8-12 weeks |
| 3 | Go-live and attestation | 4-6 weeks |
Methodology
| Weight | Factor | What it measures |
|---|---|---|
| 35% | Customer outcomes | Whether buyers get measurable operational or clinical-workflow results after go-live |
| 30% | Product | Capability depth, reliability, and fit for the job the category buys |
| 20% | Implementation | How hard it is to stand up, integrate, train, and stabilize |
| 15% | Pricing clarity | Whether a buyer can model total cost without a mystery quote |
| Label | Meaning |
|---|---|
| Highly recommend | Strong outcomes and product with manageable caveats |
| Recommend | Solid fit for the right buyer; know the tradeoffs |
| Conditional | Only with a specific use case or heavy caveats |
| Not recommended | Avoid for most buyers in this category |
Read our full methodology for how we weight scores and assign recommend labels.