Requirements for Payer to Payer CMS Interoperability Rule
Understand the requirements that will make you compliant to the Payer to Payer Data Exchange mandate under the CMS Interoperability Final Rule
Who is this rule for?
This rule applies to Medicare Advantage (MA), Medicaid Managed Care Organizations, Children’s Health Insurance Programs (CHIP) and Qualified Health Plan (QHP) issuers in the Federally-facilitated Exchange (FFE).
What do payers need to do?
CMS-regulated health plans must be able to share clinical U.S. Core Data for Interoperability (USCDI version 1) between each other when a member requests it. This includes importing historical health information from previous insurers into the members patient profile.
Policy & Compliance
Data exchange between payers must occur under two conditions:
Active Plan Member
When an active health plan member requests their clinical data to be sent to another plan
Inactive Plan Member
When an inactive health plan member is now active within another health plan
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.
How does it work?
The payer who is sending the data (Payer 1) must share it via an API infrastructure that is specific for Payer to Payer Data Exchange. This data must be shared within a single, comprehensive file for the individual patient.
The payer who receives the data (Payer 2) must incorporate it with their pre-existing data of that same patient. Payer 2 does not have to modify or act on this newly ingested data, it simply needs to be included within the patient’s record to make it a comprehensive collection of the patients’ medical history.