Anthem and Humana enter into multimillion agreement with SS&C for API cloud platform

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Anthem, Humana and SS&C Technologies have entered into a joint venture named DomaniRx to develop a claims adjudication and pharmacy benefits manager cloud platform, according to documents filed by SS&C Technologies with the Securities and Exchange Commission.

SS&C Technologies holds an 80.2% interest, and Humana and Anthem each hold a minority interest, according to the agreement filed with the SEC on July 15. 

The parties have committed up to an aggregate of approximately $925 million in the form of cash, property and/or services to support the development project, according to the filing.  

This amount includes $138,300,000 in initial cash contributions, certain assets of the parties, including a nonexclusive license to the claims processing platform known as RxNova, an assignment to a services agreement the company has with Humana, and up to approximately $400 million in cash, other property interests, and/or services. 

The development work, in addition to the day-to-day management, the performance of the Humana services agreement and the provision of certain shared services, will initially be performed by the SS&C and its affiliates under subcontract in exchange for market-based fees.

WHY THIS MATTERS

Upon completion, the cloud-native, API-driven claims adjudication platform will represent the next generation in PBMs, SS&C said in announcing the deal on July 21. It will "harmonize the payer and provider management user experience," SS&C said.

"SS&C is creating DomaniRx and we are excited to be working with two world-class founding minority co-investors. We are committed to building a next-generation claim-adjudication and PBM platform," said SS&C chairman and CEO Bill Stone in a statement.

DomaniRx will give end-to-end transparency and data analytics while adhering to the changing government regulations, the company said. 

To better address the complexity of the claims adjudication industry-wide as healthcare organizations compete and grow, DomaniRx will build a unified user experience leveraging plug-and-play technology to provide an affordable, transparent solution, SS&C said.

"This is a milestone partnership for the healthcare technology industry, and we are pleased that Humana will be our partner and first customer. DomaniRx will focus on disrupting the industry through open source technology to interface with other systems quickly," said General Manager Danny Delmastro.

"The insights we will draw from hundreds of millions of claims transactions, powered by DomaniRx's advanced processing platform, will provide participating members flexible tools, advanced analytics, and customizable programs – all while increasing transparency, accessibility and service quality for members and pharmacies."

DomaniRx's claims adjudication platform will reside on SS&C's private cloud, SS&C, founded in 1986 and headquartered in Windsor, Connecticut, provides services and software for the financial services and healthcare industries. 

THE LARGER TREND

PBMs receive and store massive amounts of data in their function of claims adjudication. The use of an Application Programming Interface, or API, allows applications to talk to each other for a faster, seamless process.

In December 2020, CMS proposed the Interoperability and Patient Access final rule, which became final on May 1. It is aimed at removing silos of information that prevent patient data exchange and promotes interoperability throughout the healthcare system.

Starting July 1, payers were required to give patients access to their data through "open" APIs, subject to the provision of HIPAA. Medicaid, CHIP and individual market Qualified Health Plans payers needed to build, implement and maintain APIs that enabled provider access to their patients' data. They were also required to streamline the prior authorization process.

AHIP pushed back against the rule earlier this year, saying it was hastily constructed, requiring insurers to build these technologies without the necessary instructions.

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com