Requirements for the Provider Directory API CMS Interoperability Rule
Understand the requirements that will make you compliant to the FHIR-based Provider Directory mandate under the CMS Interoperability Final Rule
Who is this rule for?
This rule applies to Medicare Advantage (MA), Medicaid Managed Care Organizations and Children’s Health Insurance Programs (CHIP)
What do health plans need to do?
CMS-regulated health plans must create a FHIR API-based Provider Directory that includes, for example:
MA’s that include a Medicare Advantage prescription drug plan (MA-PD), they must make available a pharmacy directory, which includes:
Type of pharmacy
Total number of in network pharmacies
How does the Provider Directory work?
Creating a publicly available Provider Directory means that all in-network information is kept in one place, encouraging better accessibility, continuity, and transparency. In addition, the consistent FHIR format enables interoperability, promoting seamless data flow between health systems.
The Provider Directory needs to be publicly available through the health plan’s website. When data is added or changed, it must be updated within 30 days.
Overall, the Provider Directory enables:
Reduced Provider Burden
Providers can easily identify and access other in-network provider information, ultimately improving workflow by facilitating referrals, transitions of care, and care coordination.
Current or prospective users can more easily identify which providers are covered by which payers, allowing them to make informed decisions about which health plans they want to enroll with.
Developers can leverage the publicly available provider information to create apps that meet patient 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.