FAQs for Payer to Payer CMS Interoperability Rule
Read the most frequently asked questions on how to meet compliance for the Payer to Payer Data Exchange mandate under the CMS Interoperability Final Rule
Frequently Asked Questions
When an inactive member has moved to another health plan, the member can request for their data to be exchanged with their current health plan. All payers must have a process in place for members to make this request, as well as the mechanism to send and receive data at their request.
Creating a publicly available and comprehensive Provider Directory means that all in-network provider information is kept in one place. With regular updates, this open resource will promote transparency, accessibility, workflow efficiency and continuity of care. In addition, the consistent FHIR format enables interoperability, promoting seamless data flow between health systems.
Enabling the sharing of member information between payers helps keep clinical data (USCDI v1) for individual patients together while they switch between health plans. This creates a comprehensive picture of their health that will open new opportunities for improving care.
All CMS-regulated payers must include the following information:
Provider names and network status
Addresses
Phone numbers
Specialities
MA’s that include a Medicare Advantage prescription drug plan (MA-PD), must also include the following information within a pharmacy directory:
Pharmacy name
Address
Phone number
Number of pharmacies in the network
Type of pharmacy
All individual health care providers, facilities, or practices must make available their Digital Contact Information. Just as payers need to provide an updated Provider Directory API, providers must maintain digital contact information in the National Plan and Provider Enumeration System (NPPES) updated.
Eligible clinicians, hospitals and CAHs in the Promoting Interoperability Program must enable Public Reporting and Information Blocking. To enforce this, CMS will publicize a list of all providers who submit a “no” response to any of the three Prevention of Information Blocking Attestation statements under the Medicare FFS Promoting Interoperability Program. Providers will have 30 days to contest this prior to publication.
Hospitals, including Psychiatric, and Critical Access Hospitals (CAHs) must enable Admission, Discharge, and Transfer (ADT) Event Notifications. Hospitals with EHRs will be required to alert providers when their patients are admitted, discharged, transferred or receive any services in the ED. This will improve coordination of care.
Currently the process for requesting data must be defined and implemented by each payer. A new payer should receive information from the member regarding their old health plan to help facilitate the data exchange. That said, CMS is working to identify ways to create an accessible, complete and accurate directory that includes endpoints. They are currently having listening sessions and conducting outreach on this topic.
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 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.
1. Interoperability: The seamless exchange of member data between payers enables the creation of an up-to-date and comprehensive patient record. This improves administrative and healthcare efficiency by reducing turnaround times, and facilitating care coordination and transitions between systems. Ultimately, this leads to:
Improved patient care
Reduced administrative burden
Greater industry potential
2. Patient Empowerment and Improved care: Previously siloed data will now be able to flow seamlessly between payers upon member request. This puts patients in charge of their own information and therefore in control of the future of their personal health. The Payer to Payer Exchange API enables data to follow individual patients across disparate health plans, ensuring that no information is lost. Examples of meaningful data flow:
When a patient ages into Medicare
When a patient changes health plan
When a patient is dually-eligible for both MA plans and Medicaid managed care plans
This patient continuity allows for a comprehensive picture of an individual’s health. This also facilitates informed decision-making, where a patient can choose which health plan to enroll with. Patient empowerment ultimately enables individuals to more effectively manage their own health, care and costs. Together, improved data flow, patient continuity, and empowerment improve health care outcomes.
3. Reduced Administrative Burden: The increased automation enabled by the use of a specialized Payer to Payer Data Exchange API reduces the administrative burden for both payers and providers. For payers, work and cost-efficiency is improved. For providers, high-quality coordinated care is made possible.
4. Broader Industry Potential: Payer to Payer Data Exchange is built on top of the Patient Access API rule. This means that years of health care data, that was made available through the Patient Access API, can now be exchanged between payers and enable:
Minimization of burdens Cost reduction
Transparency between payers and patients, who can access the same information within the same time-frame
Creation and maintenance of a comprehensive health record
Together, these will broaden industry potential. It will be possible to introduce analytical capabilities through which both payers and providers can gain valuable insights that will ultimately open new frontiers in health care.
1. Interoperability Improves Workflow Efficiency and Reduces Provider Burden:
The FHIR format enables interoperability, promoting seamless data flow between health systems. Having data in a consistent format also reduces provider burden. Providers can easily identify and access other in-network provider information, like:
Provider type
Specialty
Contact information
Whether they’re currently accepting new patients
All of this facilitates referrals, transitions of care, and care coordination across providers covered by the same health plan. This ultimately improves workflow efficiency and patient care.
2. Accessibility Enables Patient Empowerment:
With provider information all in one place, the content itself is also regulated: health plans must make all provider data adhere to the standard FHIR-format and publish the directory on their website. This ensures accessibility, continuity, and transparency. As a result, patients are empowered with information: current or prospective users can more easily identify which providers are covered by which payers, enabling them to make informed decisions about which health plans they want to be enrolled with.
3. API Enables Third-party Applications that Meet Individual Care Needs:
The benefit of making provider information available on an API is that third-party developers can build off of the provider data to create apps for the benefit of health plan user needs. For example, an app can help prospective health plan users compare in-network providers by identifying available specialties, hours of operation, and languages spoken. This then enables individuals to choose which health plan they want to enroll with. Connecting users to providers, apps can more efficiently meet individual health care needs.
Today, 83% of healthcare institutions are using the Cloud for apps.
Cloud-based servers have high uptime guarantees, optimal security, and require low implementation and maintenance effort. With single tenant or managed offering, and API access for internal usage, health plans can have full access to the system with direct account access to all databases. There are no compromises for this access as payers are the owners of the data. The cloud enables scalability with data from hundreds of customers, including large health plans with millions of members.
Cloud implementation has more benefits compared to utilizing servers on-premises:
1. Security: tested by hundreds of developers, it’s not dependent on local networking and it is resilient to DDOS
2. Low cost: it costs less as a service because there is no need for on premises hosting or management
3. High Speed: it’s quicker to deploy, provides better performance and scalability, and smoothly implements new features
Today, 83% of healthcare institutions are using cloud for apps.
Cloud-based servers have high uptime guarantees, optimal security, and require low implementation and maintenance effort. With single tenant or managed offering, and API access for internal usage, health plans can have full access to the system with direct account access to all databases. There are no compromises for this access as payers are the owners of the data. The cloud enables scalability with data from hundreds of customers, including large health plans with millions of members.
Cloud implementation has more benefits compared to utilizing servers on-premises:
1. Security: tested by hundreds of developers, it’s not dependent on local networking and it is resilient to DDOS
2. Low cost: it costs less as a service because there is no need for on premises hosting or management
3. High Speed: it’s quicker to deploy, provides better performance and scalability and smoothly implements new features
CMS created a Best Practices for Payers and App Developersdocument, which provides links to useful information and best practices to help you build and maintain a FHIR-based API, as well as best practices for payers and third-party app developers.
CMS created a Best Practices for Payers and App Developers document, which provides links to useful information and best practices to help you build and maintain a FHIR-based API, as well as best practices for payers and third-party app developers.
CMS has provided the Da Vinci PDEX Plan Net IG implementation guide (IG) for the development of the Provider Directory API. While use of this IG is not required, it is highly recommended that payers leverage IGs when developing their APIs to avoid duplicative efforts. CMS has been working with HL7 and other industry partners to ensure such resources are freely available to payers.