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Summary of the FHIR-based Provider Directory CMS Interoperability Rule

Understand the compliance requirements and find the key deadline to comply to the CMS mandated Provider Directory API Policy

CMS regulated health plans must make a Provider Directory by implementing a FHIR-based API that is publicly available on their website.

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.

Provider Directory API endeavours to: 

  • Enable patient access to in-network provider and drug formulary information

  • Improve interoperability and care coordination across providers

  • Promote transparency and care continuity

All while reducing burden and costs on payers and providers.

Who

CMS-regulated payers, like: 

  • Medicare Advantage (MA)

  • Medicaid Managed Care Organizations 

  • Children’s Health Insurance Programs (CHIP)

How

Developers can utilize HL7’s open-source Da Vinci Payer Data Exchange (PDEX) Plan Network IG.

What

Payers must make all of their in-network provider data available in a FHIR® 4.0.1 (R4) format within the Provider Directory API.

Why

The Provider Directory API is being introduced across the U.S. because  it enables: 

  • Interoperability

  • Workflow efficiency

  • Provider burden reduction

  • Accessibility

  • Patient empowerment

  • Third-party applications

When

All health plans must comply with the CMS Provider Directory API by the 1st of July, 2021.

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