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


Get in Touch

Contact us to find more about the CMS rule, how it applies to your company, and about leading vendor solutions. 

We received your message and will contact you back soon.

Error sending please try again