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Summary of Payer to Payer CMS Interoperability Rule

Understand the compliance requirements and find the key deadline to comply with the CMS mandated Payer to Payer Data Exchange Policy

CMS regulated health plans must share clinical data (USCDI v1) to another health plan at the members request.

In a nutshell:


The challenge is that, currently, health systems are not built to enable interoperability and data exchange between payers.

Lack of seamless data exchange in healthcare has historically detracted from patient care, leading to poor health outcomes, and higher costs.

Payer to Payer Data Exchange endeavours to: 

  • Enable better patient access to their health information

  • Improve interoperability

  • Promote care continuity

All while reducing burden and costs on payers and providers.


CMS-regulated health plans:

  • Medicare Advantage (MA)

  • Medicaid Managed care plans 

  • Children’s Health Insurance Programs (CHIP)

  • Qualified Health Plan (QHP) issuers in the Federally-facilitated Exchange (FFE)


Clinical U.S. Core Data for Interoperability (USCDI version 1) must become transferable between payers. This can be achieved through the Clinical Data (in USCDI v1) HL7 FHIR® US Core Implementation Guide STU 3.1.0.


Payers must enable clinical data exchange, upon member request, and ingest it into their own database. This Payer to Payer Data Exchange occurs using a specially built API and applies to health plan member data from the previous five years, therefore from or after the 1st of January 2016.


The Payer to Payer Data Exchange regulation is being introduced across the U.S. because it enables: 

  • Interoperability

  • Patient empowerment 

  • Patient data continuity 

  • Reduced payer and provider burden 

  • Improved health care outcomes

  • Industry potential


All CMS-regulated payers must comply with the Payer to Payer Exchange mandate by the 1st of January, 2022.

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