Tech Specifications for Payer to Payer Data Exchange API
Find the technical specifications and implementation guidelines you need to become compliant to the Payer to Payer Data Exchange mandate under the CMS Final Rule
Payer to Payer Data Exchange API
The Payer to Payer Exchange API enables data to follow individual patients across disparate health plans, ensuring that no information is lost. The Centers for Medicaid and Medicare Services (CMS) has been working with HL7 and other industry partners to ensure that implementation guides and other resources are freely available to payers to use in meeting the Payer to Payer requirements, although these are not mandatory.
Improving Healthcare Interoperability
Payer to Payer Data Exchange is a component of the CMS Patient Access and Interoperability Rule, and builds on the preceding Patient Access API requirements (enforced from July 1, 2021). This means that years of healthcare data, that was made available through the Patient Access API, can now be exchanged between payers and enable:
Improved member experience
Transparency between payers and patients, who can access the same information within the same timeframe
Creation and maintenance of a longitudinal health record
USCDI Clinical Data
To enable coordination and sharing of clinical data for the Payer to Payer Data Exchange API, CMS requires, at minimum, the use of United States Core Data for Interoperability (USCDI) version 1 health data sets. The USCDI V1 is a standardized set of health data classes and component data elements for nationwide, interoperable health information exchange.
In order to enable former health plan members to share their data with a new health plan for up to 5 years after they have disenrolled, health plans will need to provide a means for member authentication for former members.
There are two approaches for member authentication:
Identity Provider (IdP) - Based
Former members can use their previous IdP portal credentials to sign in. Considerations need to be made for former members who never previously registered with the member portal
Zero Knowledge Based
Former members provide key pieces of information to verify their identity such as Name, Date of Birth, Previous Member ID, Zip code
The preferred way to enable this clinical data exchange is through HL7’s FHIR Release 4.0.1, given the prior investment in transforming these same clinical data elements to FHIR R4 for the Patient Access APIs. These resources define the content and structure of core health data, which can be used by developers to build standardized applications.
HL7 has made available open-source implementation guides that can be helpful for payers who want to implement the Final Rule via FHIR. The use of these guides is not mandatory, but using these guides can help payers save both time and resources.