CMS Rule

What data needs to be included in the Patient Access API and the Provider Directory API?

Payers must be prepared to expose the following data points via APIs by January 1, 2021:


Patient Access API Data Points

Provider Directory API Data Points 

Included
  • Adjudicated claims (including Pharma)
  • Encounters with capitated providers
  • Provider remittances
  • Enrollee cost-sharing
  • Subset of clinical data, including laboratory results (where maintained by the impacted payer and defined as the classes of data stipulated in USCDI v.1)
  • Formularies or preferred drug lists*

  • MA-PD plans must also include:
  • Covered drugs, and any tiered formulary structure or utilization management procedure
  • Provider names and network status
  • Addresses
  • Phone numbers
  • Specialities

  • MA-PD plans must also include:
  • Pharmacy name
  • Address
  • Phone number
  • Number of pharmacies in the network
  • Type of pharmacy
Notes All payers except QHPs on the FFEs must make the Provider Directory API accessible via a public-facing digital endpoint on their website to ensure public discovery and access
Timing
No later than one (1) business day after a claim is adjudicated or encounter data is received by the impacted payer Within 30 days of receipt of new data or changes to directory data

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