Payer to Payer
Data Exchange
Learn about CMS Payer to Payer Data Exchange APIs, Interoperability, and additional FHIR® requirements for health plans. Get live by the required deadline, Jan 1, 2023!
Understanding the CMS Requirements for Payers
CMS-regulated health plans need to make it possible to exchange clinical data with another health plan when a member requests it. The data that payers exchange is, at minimum, U.S. Core Data for Interoperability (USCDI) version 1. Payers must be able to send, receive, and incorporate enrollee USCDI data from the period they were covered, from January 1st, 2016, and for up to 5 years after coverage ends.
This will be achieved through the following:
Receive Member Data
A payer must be able to receive data from another health plan spanning up to the previous 5 years the patient was insured by them.
Communicate with New Health Plan
A payer needs to be able to send their member’s data, during and up to 5 years after their cover ends, to the new health plan that now insures the patient.
Send Member Data
A payer needs to be able to send their member’s data, during and up to 5 years after their cover ends, to any other recipient identified by the patient.
Achieving Interoperability
An upcoming proposed CMS rule “Reducing Provider and Patient Burden by Improving Prior Authorization Processes, and Promoting Patients’ Electronic Access to Health Information” (CMS-9123-P), suggests that the Payer to Payer Data Exchange will occur at the time of member enrollment and be expanded beyond just clinical (USCDI v1) data. This rule is not yet final; based on the proposed rule it is expected to take effect on January 1st, 2023.
This exchange of health information must be facilitated through an API. One way this can be done is by using a Fast Healthcare Interoperability Resources (FHIR) based API. FHIR is an open source data format provided by HL7 that promotes interoperability between systems. This is because FHIR enables data interactivity (reading and writing), atomic data access (allowing specific data queries) and flexibility for developers. All of these FHIR benefits make it a useful tool for the Payer to Payer Data Exchange.
Why This Matters
Payer to Payer Data Exchange promotes interoperability which ultimately enables coordination of care, patient empowerment, and reduced administrative burden, as patients can take their health data with them when they switch insurance companies.
Together, these benefits enabled by the Payer to Payer Data Exchange will broaden industry potential. It will be possible to introduce analytical capabilities through which both payers and providers can gain valuable insights that will open new frontiers in health care.
1upHealth’s Solution
1upHealth provides a fully managed solution to cover all new mandates. Today, 100s of apps use 1up FHIR APIs to manage user directed connectivity across 1000s of health systems that we helped attest to similar patient access mandates. Plans can use the same infrastructure to meet all patient access and interop requirements.