CMS Patient Access Rule Requirements

Requirements for Payers

1

Implement, test, and maintain a secure, standards-based Patient Access API using HL7 FHIR Release 4.0.1

2

Make standardized information about provider networks available via a FHIR-based API using HL7 FHIR Release 4.0.1

3

Engage in standards-based, electronic Payer-to-Payer Data Exchange using USCDI v1, enabling beneficiaries to import historical health information from previous insurers into their patient profile. Payers are only obligated, at a minimum, to send data received from another payer under this policy in the electronic form and format it was received.

	Patient Access API	Provider Directory API	Payer-to-Payer Data Exchange
Who	MA organizations State Medicaid FFS programs Medicaid managed care plans CHIP FFS programs CHIP managed care entities QHP issuers on the FFEs	MA organizations State Medicaid FFS programs Medicaid managed care plans CHIP FFS programs CHIP managed care entities QHP issuers on the FFEs	MA organizations Medicaid managed care plans CHIP managed care entities QHP issuers on the FFEs
Required Data	Adjudicated claims (including Pharmacy) Encounters with capitated providers Provider remittances Enrollee cost-sharing Subset of clinical data including lab results (where maintained by the impacted health plan) Formularies or preferred drug lists	Provider names and network status Addresses Phone numbers Specialities	Clinical data specified under U.S. Core Data for Interoperability (USCDI) version 1
Security	3rd party access managed by OAuth 2.0 tokens	API endpoint on public website
Implementation Guide	CARIN Alliance Blue Button® Framework and Common Payer Consumer Data Set (CPCDS) IG	Da Vinci Payer Data Exchange (PDEX) Plan Network IG	Clinical Data (in USCDI v1) HL7 FHIR® US Core IG STU 3.1.0
Data Standard	FHIR® 4.0.1 (R4) API	FHIR® 4.0.1 (R4) API	FHIR® 4.0.1 (R4) API

Non-payer requirements in the rule

Improving the Dually Eligible Experience by Increasing the Frequency of Federal-State Data Exchanges
Public Reporting and Information Blocking (late 2020)
Digital Contact Information (late 2020)
Admission, Discharge, and Transfer Event Notifications (late 2020)

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