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Payer to Payer Data Exchange: General Information

Find all the information you need to meet compliance for the Payer to Payer Data Exchange CMS Interoperability Final Rule

What do payers need to do?

CMS-regulated health plans need to make it possible to exchange clinical data with another health plan when a member requests it. The data that payers exchange is, at minimum, U.S. Core Data for Interoperability (USCDI) version 1. Payers must be able to send, receive, and incorporate enrollee USCDI data from the period they were covered, from January 1st, 2016, and for up to 5 years after coverage ends. Specifically: 


Receive Member Data

A payer needs to be able to receive data from another health plan spanning up to the previous 5 years the patient was insured by them 


New Health Plan

A payer needs to be able to send their member’s data, during and up to 5 years after their cover ends, to the new health plan that now insures the patient


Send Member Data

A payer needs to be able to send their member’s data, during and up to 5 years after their cover ends, to any other recipient identified by the patient

The Problem

We live in a world where data fuels decisions. Healthcare industry data, however, is siloed within separate stakeholder systems. This makes it difficult and expensive to obtain a holistic view of a patient’s health information and ultimately prevents people from receiving the best possible care. 

The Centers for Medicare and Medicaid Services (CMS) is tackling this problem through the Interoperability and Patient Access Final Rule. Part of this rule requires health plans to enable Payer to Payer Data Exchange by January 1st, 2022.

Doctor's Appointment

Achieving Interoperability

This exchange of health information must be facilitated through an API. One way this can be done is by using a Fast Healthcare Interoperability Resources (FHIR) based API. FHIR is an open source data format provided by HL7 that promotes interoperability between systems. This is because FHIR enables data interactivity (reading and writing), atomic data access (allowing specific data queries) and flexibility for developers. All of these FHIR benefits make it a useful tool for the Payer to Payer Data Exchange. 

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 Data 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. 

X-Ray Results

The Overall Goal

Payer to Payer Data Exchange promotes interoperability which ultimately enables coordination of care, patient empowerment, and reduced administrative burden, as patients can take their health data with them when they switch insurance company. 

Together, these benefits enabled by the Payer to Payer Data Exchange will broaden industry potential. It will be possible to introduce analytical capabilities through which both payers and providers can gain valuable insights that will open new frontiers in health care.

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