Who We Serve / Payers, ACOs & Employers
Payers · ACOs · Employers
Medicaid managed care organizations, commercial and Blues plans, Medicare Advantage plans, third-party administrators, accountable care organizations, and self-insured employers use SCeHA to close gaps in care, receive event-based notifications on attributed lives, and satisfy CMS interoperability and prior-authorization rules.
Who this is for
If your organization holds actuarial or contractual risk on South Carolina lives — or funds a self-insured population — SCeHA is the shared infrastructure that gives you real-time visibility.
The value case
Civitas and POCP both position payers as principal HIE beneficiaries — driven by avoidable-utilization savings, care-management effectiveness, and regulatory compliance.
Real-time ADT alerts give your care management teams a same-day intervention window that phone-based approaches never reach.
Population Explorer and longitudinal record access surface missed screenings, lapsed medications, and follow-up opportunities.
Access to clinical data supports payer-to-payer, patient-access, and prior-authorization API requirements.
Clinical context at the point of prior authorization improves speed and reduces provider abrasion.
Better data supports better performance under shared-savings, capitation, and quality-based contracts.
Civitas HDU Framework →Civitas explicitly identifies self-insured employers as HDU funding partners for workforce wellness analysis.
What you use
Where the participant holds a patient relationship (delivers care or is contractually responsible), the full clinical stack is included. Without a patient relationship, participation focuses on ADT event notifications and panel-based analytics.
| SCeHA service | How you use it |
|---|---|
| Encounter Notification Service | Templated ADT alerts on attributed panel — near real-time or SFTP-batched daily. |
| Provider Portal / InContext | Included where ACO/MCO holds a direct patient relationship — care managers access the full record. |
| Population Explorer | Encounter-history analytics for high-utilizer identification, care-management targeting, and gap closure. |
| Query & Retrieve | On-demand clinical record pull for utilization management and prior authorization support. |
| Direct Secure Messaging | Provider communication for care management and closed-loop referral programs. |
"Tangible value of advanced HIE to payers includes prevention of avoidable inpatient admissions, reduction in avoidable ED utilization, improved quality-reporting workflows, and reduced cost of distributing clinical reports to physicians."
Adapted from POCP Value of HIE from the Payer's PerspectiveParticipation & pricing
MCOs are priced under a progressive tiered PMPM methodology so that larger plans benefit from lower marginal rates. ACOs and self-insured employers are priced based on the specific participation scope.
Fees shown are 2026 rates. Larger organizations qualify for tiered discounts. Full detail in the current SCeHA HIE Fee Schedule.
| Participant type | 2026 subscription |
|---|---|
| MCO — first 200,000 members | $0.08 PMPM |
| MCO — 200,001–500,000 members | $0.06 PMPM |
| MCO — 500,001+ members | $0.04 PMPM |
| ACO (with or without direct patient relationship) | PMPM — negotiated |
| Self-insured employer | Negotiated (Other Organizations) |
Evidence base
POCP's payer-perspective toolkit estimates $21.6B annual net U.S. value of advanced HIE to payers — driven by avoidable-utilization and workflow effects.
POCP Payer Toolkit →Civitas explicitly identifies commercial payers, Medicaid, Medicare, and self-insured employers as HDU stakeholders and funding partners.
Civitas HDU Framework →CMS finalized rules requiring payers to make claims, encounter, and clinical data available via FHIR APIs — HIE participation accelerates compliance.
CMS-9115-F final rule →Ready to participate?
Tell us about your organization and a SCeHA representative will walk you through the participation agreement, technical onboarding, and go-live plan. Standard onboarding activates within 60–90 days.
Start the sign-up process →Prefer to talk first? Contact SCeHA directly.